Provider Demographics
NPI:1447887096
Name:MOORE, BENJAMIN J (PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:J
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:4920 S 30TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1656
Mailing Address - Country:US
Mailing Address - Phone:402-734-4110
Mailing Address - Fax:402-734-3990
Practice Address - Street 1:4920 S 30TH ST STE 103
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1656
Practice Address - Country:US
Practice Address - Phone:402-734-4110
Practice Address - Fax:402-734-3990
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2020-08-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NE2508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant