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NPI Code Detail

MEDICARE: MR. KELLY L. MOORES PA-C

MEDICARE: MR. KELLY L. MOORES 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
1363AS0400XSurgical Physician Assistant

Other Identifiers

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

General Provider Information

NPI Number : 1417937194
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. KELLY L. MOORES PA-C
Provider Business Mailing Address
First Line : 1324 LAKELAND HILLS BLVD
Second Line : ATTN: MANAGED CARE DEPT
City : LAKELAND
State : FL
Zip : 33805-4543
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2400 KATHLEEN RD
Second Line :
City : LAKELAND
State : FL
Zip : 33810-3077
Country : US
Telephone Number : 863-687-1250
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/19/2006
Last Update Date : 02/11/2026

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