Healthcare Provider Details

I. General information

NPI: 1609764729
Provider Name (Legal Business Name): SETH MOORE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N WABASH AVE STE 110
MARION IN
46952-2677
US

IV. Provider business mailing address

6308 WOODCHUCK DR
PENDLETON IN
46064-9076
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-1201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10005011A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: