Healthcare Provider Details

I. General information

NPI: 1467112250
Provider Name (Legal Business Name): JOHNATHAN M MOORE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 GREEN HOLLOW RD
DANIELSON CT
06239-3533
US

IV. Provider business mailing address

325 N JAMES ST APT 2
PEEKSKILL NY
10566-2486
US

V. Phone/Fax

Practice location:
  • Phone: 860-779-1865
  • Fax:
Mailing address:
  • Phone: 401-300-7652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: