Provider Demographics
NPI:1447227285
Name:MOORE, CHARLES K (FNP)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:K
Last Name:MOORE
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4190
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4190
Mailing Address - Country:US
Mailing Address - Phone:304-399-4405
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:2828 1ST AVE
Practice Address - Street 2:SUITE 510
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1236
Practice Address - Country:US
Practice Address - Phone:304-399-7533
Practice Address - Fax:304-399-7507
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4411P363L00000X
WV50644363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100008460Medicaid
WVP00892178OtherRR MEDICARE
OH2654266Medicaid
WV3810004812Medicaid
OH2654266Medicaid
KY7100008460Medicaid