Provider Demographics
NPI:1447241831
Name:MOORE, PERRY ALAN (PA-C)
Entity type:Individual
Prefix:
First Name:PERRY
Middle Name:ALAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 S CHICKASAW TRL STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-3501
Mailing Address - Country:US
Mailing Address - Phone:407-303-6865
Mailing Address - Fax:407-303-6537
Practice Address - Street 1:258 S CHICKASAW TRL STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-3501
Practice Address - Country:US
Practice Address - Phone:407-303-6865
Practice Address - Fax:407-303-6537
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101891363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291760200Medicaid
FL291760200Medicaid
FLE8111YMedicare PIN