MEDICARE: MR. JAMES MOORE P.A.

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	363AS0400X	Surgical Physician Assistant
2	363AS0400X	Surgical Physician Assistant	PA9103288	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053302059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES MOORE P.A.

Provider Business Mailing Address
First Line	:	PO BOX 510764
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-0764
Country	:	US
Telephone Number	:	321-684-1193
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 AMBERJACK PL
Second Line	:
City	:	MELBOURNE BEACH
State	:	FL
Zip	:	32951-2906
Country	:	US
Telephone Number	:	321-684-1193
Fax Number	:

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

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/21/2022

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