Healthcare Provider Details

I. General information

NPI: 1083825277
Provider Name (Legal Business Name): KYLE ANDRE MOORE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2007
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 STRAIGHT ST
PATERSON NJ
07503-3239
US

IV. Provider business mailing address

91 21ST ST
IRVINGTON NJ
07111-4558
US

V. Phone/Fax

Practice location:
  • Phone: 973-782-5550
  • Fax: 973-782-5548
Mailing address:
  • Phone: 973-373-1819
  • Fax: 973-373-1819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number40QB00186200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: