Healthcare Provider Details

I. General information

NPI: 1497901029
Provider Name (Legal Business Name): ANTHONY ALLEN MOORE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4215 EDGEWATER DR
ORLANDO FL
32804-2206
US

IV. Provider business mailing address

695 US HIGHWAY 46 STE 400A
FAIRFIELD NJ
07004-1568
US

V. Phone/Fax

Practice location:
  • Phone: 855-582-7747
  • Fax: 888-972-4761
Mailing address:
  • Phone: 973-894-1265
  • Fax: 888-972-6480

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9104697
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: