MEDICARE: MR. JON G. MOORE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	118222	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	431560263	OTHER	MO	TRICARE
2	P01262378	OTHER	MO	RR MCR

General Provider Information

NPI Number	:	1003805201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JON G. MOORE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 2580
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65801-2580
Country	:	US
Telephone Number	:	417-829-4620
Fax Number	:

Provider Business Practice Location Address
First Line	:	608 OLD ROUTE 66
Second Line	:
City	:	SAINT ROBERT
State	:	MO
Zip	:	65584-3730
Country	:	US
Telephone Number	:	573-336-5100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	03/13/2014

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