MEDICARE: KABRIEL MOOREHEAD 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	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	10832	GA

General Provider Information

NPI Number	:	1043831449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KABRIEL MOOREHEAD PA-C

Provider Business Mailing Address
First Line	:	1390 NORTHSIDE DR NW APT 2421
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-1837
Country	:	US
Telephone Number	:	904-318-7009
Fax Number	:

Provider Business Practice Location Address
First Line	:	1390 NORTHSIDE DR NW APT 2421
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30318-1837
Country	:	US
Telephone Number	:	904-318-7009
Fax Number	:

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

Provider Enumeration Date	:	04/27/2020
Last Update Date	:	03/01/2022

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