Healthcare Provider Details

I. General information

NPI: 1013099068
Provider Name (Legal Business Name): ANGELO DEWITT MOORE FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 STEPHENSON AVE PATTERSON ARMY HEALTH CLINIC
FORT MONMOUTH NJ
07703-5000
US

IV. Provider business mailing address

21 MILLENNIUM LOOP
STATEN ISLAND NY
10309-4337
US

V. Phone/Fax

Practice location:
  • Phone: 732-532-0182
  • Fax: 732-532-0194
Mailing address:
  • Phone: 718-630-4186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number138235
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number648115
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: