Healthcare Provider Details

I. General information

NPI: 1215896642
Provider Name (Legal Business Name): KIERSTEN MOORE MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 CHARTER DR STE 205
COLUMBIA MD
21044-3687
US

IV. Provider business mailing address

10700 CHARTER DR STE 205
COLUMBIA MD
21044-3687
US

V. Phone/Fax

Practice location:
  • Phone: 443-997-2663
  • Fax:
Mailing address:
  • Phone: 443-510-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0010710
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: