MEDICARE: MRS. LAURA ANN MOORE RPA-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	207Q00000X	Family Medicine Physician	003362 1	NY
2	363AM0700X	Medical Physician Assistant	3362	NY
3	363AM0700X	Medical Physician Assistant	003362	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P019003362	OTHER	NY	BLUE CHOICE
2	PA0030	OTHER	NY	PREFERRED CARE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1467466268
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA ANN MOORE RPA-C

Provider Business Mailing Address
First Line	:	3669 COUNTRYSIDE LN
Second Line	:
City	:	MARION
State	:	NY
Zip	:	14505-9781
Country	:	US
Telephone Number	:	315-926-7733
Fax Number	:	315-926-0731

Provider Business Practice Location Address
First Line	:	3669 COUNTRYSIDE LN
Second Line	:
City	:	MARION
State	:	NY
Zip	:	14505-9781
Country	:	US
Telephone Number	:	315-926-7733
Fax Number	:	315-926-0731

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

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	06/29/2023

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