MEDICARE: MRS. ANGELIA RENEE' 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	363AM0700X	Medical Physician Assistant	0110004893	VA

General Provider Information

NPI Number	:	1033504857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANGELIA RENEE' MOORE PA-C

Provider Business Mailing Address
First Line	:	6439 IRON BRIDGE RD
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23234-5205
Country	:	US
Telephone Number	:	804-271-8990
Fax Number	:

Provider Business Practice Location Address
First Line	:	6439 IRON BRIDGE RD
Second Line	:
City	:	NORTH CHESTERFIELD
State	:	VA
Zip	:	23234-5205
Country	:	US
Telephone Number	:	804-271-8990
Fax Number	:

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

Provider Enumeration Date	:	03/30/2015
Last Update Date	:	03/30/2015

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