=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154710077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL AUSTIN MOORE PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2015
-----------------------------------------------------
Last Update Date | 09/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 345 W STEAMBOAT DR
-----------------------------------------------------
City | DAKOTA DUNES
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57049-5333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-217-5617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 345 W STEAMBOAT DR STE 601
-----------------------------------------------------
City | DAKOTA DUNES
-----------------------------------------------------
State | SD
-----------------------------------------------------
Zip | 57049-5287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 605-217-5617
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 076565
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1292
-----------------------------------------------------
License Number State | SD
-----------------------------------------------------