Healthcare Provider Details

I. General information

NPI: 1104823277
Provider Name (Legal Business Name): JOSEPH MOORE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 POCAHONTAS TRL
QUINTON VA
23141-1657
US

IV. Provider business mailing address

1850 POCAHONTAS TRL
QUINTON VA
23141-1657
US

V. Phone/Fax

Practice location:
  • Phone: 804-932-4388
  • Fax: 804-932-9860
Mailing address:
  • Phone: 804-932-4388
  • Fax: 804-966-9860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110840202
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: