Healthcare Provider Details

I. General information

NPI: 1851089684
Provider Name (Legal Business Name): JACOB MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2023
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 WAIANUENUE AVE
HILO HI
96720-2020
US

IV. Provider business mailing address

159 MARGARET ST STE 100
PLATTSBURGH NY
12901-1874
US

V. Phone/Fax

Practice location:
  • Phone: 808-932-3000
  • Fax:
Mailing address:
  • Phone: 518-314-3939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDOS-2998
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: