Healthcare Provider Details

I. General information

NPI: 1770514614
Provider Name (Legal Business Name): MARY L MOORE PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 E HACKBERRY ST
PEARSALL TX
78061-4412
US

IV. Provider business mailing address

151 ENCINO DRIVE
PEARSALL TX
78061
US

V. Phone/Fax

Practice location:
  • Phone: 830-334-3670
  • Fax: 830-334-3672
Mailing address:
  • Phone: 830-334-3670
  • Fax: 830-334-3672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA02513
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: