Healthcare Provider Details

I. General information

NPI: 1659136240
Provider Name (Legal Business Name): WILESHA SHANISE MOORE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

545 W BUTLER RD
GREENVILLE SC
29607-4833
US

IV. Provider business mailing address

545 W BUTLER RD
GREENVILLE SC
29607-4833
US

V. Phone/Fax

Practice location:
  • Phone: 864-299-1990
  • Fax: 864-299-9123
Mailing address:
  • Phone: 864-299-1990
  • Fax: 864-299-9123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6106
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: