Healthcare Provider Details

I. General information

NPI: 1902348915
Provider Name (Legal Business Name): MICHAEL R. MOORE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2016
Last Update Date: 01/24/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 112TH AVE NE STE C260
BELLEVUE WA
98004-3746
US

IV. Provider business mailing address

510 8TH AVE NE STE 320
ISSAQUAH WA
98029-5436
US

V. Phone/Fax

Practice location:
  • Phone: 425-313-3055
  • Fax: 425-313-3051
Mailing address:
  • Phone: 425-313-3055
  • Fax: 425-313-3051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60662480
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: