1790853422 NPI number — DOUGLAS BERNARD MOORE PA-C

Table of content: DOUGLAS BERNARD MOORE PA-C (NPI 1790853422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790853422 NPI number — DOUGLAS BERNARD MOORE PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
DOUGLAS
Provider Middle Name:
BERNARD
Provider Name Prefix Text:
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:
1790853422
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1535
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98401-1535
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-761-4200
Provider Business Mailing Address Fax Number:
253-383-3553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1304 FAWCETT AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98402-1911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-761-4200
Provider Business Practice Location Address Fax Number:
253-383-3553
Provider Enumeration Date:
12/01/2006

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: 363AM0700X , with the licence number:  PA10005095 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA10005095 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0215666 . This is a "LABOR AND INDUSTRIES-TRA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8862653 . This is a "MEDICARE PIN-TRA KING" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8943157 . This is a "LABOR AND INDUSTRIES CRIME VICTIMS-TRA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: P00428602 . This is a "RR MEDICARE-TRA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8862652 . This is a "MEDICARE PIN-TRA PIERCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8862654 . This is a "MEDICARE PIN-UNION AVENUE OPEN MRI" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0249530 . This is a "LABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8951854 . This is a "LABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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