MEDICARE: TINA ANN WILKINSON MOORE PA

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	PA03112	TX

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	8F9743	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1124013198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA ANN WILKINSON MOORE PA

Provider Business Mailing Address
First Line	:	5700 E I 20 SERVICE RD S
Second Line	:
City	:	WILLOW PARK
State	:	TX
Zip	:	76008-5115
Country	:	US
Telephone Number	:	817-737-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 E I 20 SERVICE RD S
Second Line	:
City	:	WILLOW PARK
State	:	TX
Zip	:	76008-5115
Country	:	US
Telephone Number	:	817-489-7300
Fax Number	:	817-489-7302

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	01/28/2019

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Directions to “ TINA ANN WILKINSON MOORE PA” Practice Location

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