Provider Demographics
NPI:1447456074
Name:MOORE, TERRIA (PA)
Entity type:Individual
Prefix:MRS
First Name:TERRIA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:FORT EUSTIS
Mailing Address - State:VA
Mailing Address - Zip Code:23604-1373
Mailing Address - Country:US
Mailing Address - Phone:706-562-4348
Mailing Address - Fax:757-314-7601
Practice Address - Street 1:576 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:FORT EUSTIS
Practice Address - State:VA
Practice Address - Zip Code:23604-1373
Practice Address - Country:US
Practice Address - Phone:757-314-7602
Practice Address - Fax:757-314-7601
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010002446363A00000X
GA005591363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant