Healthcare Provider Details

I. General information

NPI: 1497389811
Provider Name (Legal Business Name): CLIFFORD ANDREW MOORE NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 03/13/2022
Certification Date: 03/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10180 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

10180 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

V. Phone/Fax

Practice location:
  • Phone: 210-269-9289
  • Fax:
Mailing address:
  • Phone: 210-269-9289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number202200913NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP61256697
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: