Healthcare Provider Details

I. General information

NPI: 1114671765
Provider Name (Legal Business Name): ALYSSA K MOORE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

IV. Provider business mailing address

9166 PORTER RD
RYLAND HGHT KY
41015-9587
US

V. Phone/Fax

Practice location:
  • Phone: 513-865-5552
  • Fax: 513-865-2227
Mailing address:
  • Phone: 513-766-2874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.0007057
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.007057RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: