Healthcare Provider Details

I. General information

NPI: 1982864278
Provider Name (Legal Business Name): ALANNA C MOORE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALANNA C MOOREHEAD PA-C

II. Dates (important events)

Enumeration Date: 06/11/2008
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1072 N LIBERTY ST SUITE 203
BOISE ID
83704-8708
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-4321
  • Fax: 208-367-4525
Mailing address:
  • Phone: 208-367-5170
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-746
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: