Healthcare Provider Details

I. General information

NPI: 1255883013
Provider Name (Legal Business Name): SARAH MOORE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CLAY ST
MALONE NY
12953-1905
US

IV. Provider business mailing address

5 CLAY ST
MALONE NY
12953-1905
US

V. Phone/Fax

Practice location:
  • Phone: 518-483-0705
  • Fax:
Mailing address:
  • Phone: 518-483-0705
  • Fax: 518-483-1375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number020259-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: