Healthcare Provider Details

I. General information

NPI: 1881701308
Provider Name (Legal Business Name): PAMELA M MOORE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PAMELA M YODER ANP

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 05/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W. PARK ST. CARDIOLOGY
URBANA IL
61801-2500
US

IV. Provider business mailing address

611 W. PARK ST. BWPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-904-7000
  • Fax: 217-904-7742
Mailing address:
  • Phone: 217-383-6792
  • Fax: 217-383-4752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209-006880
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberRN81005
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: