1700053394 NPI number — MR. MATTHEW HENRY MOORE PA-C

Table of content: MR. MATTHEW HENRY MOORE PA-C (NPI 1700053394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700053394 NPI number — MR. MATTHEW HENRY MOORE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
MATTHEW
Provider Middle Name:
HENRY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700053394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 S TREATY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74354-5327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-540-1511
Provider Business Mailing Address Fax Number:
918-542-7374

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 S TREATY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-540-1511
Provider Business Practice Location Address Fax Number:
918-542-7374
Provider Enumeration Date:
05/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  1732 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200207110A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100736700O , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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