Provider Demographics
NPI:1871317024
Name:MOORE, PAUL
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 BRYN MAWR CIR
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8919
Mailing Address - Country:US
Mailing Address - Phone:479-459-2625
Mailing Address - Fax:
Practice Address - Street 1:9000 BRYN MAWR CIR
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72908-8919
Practice Address - Country:US
Practice Address - Phone:479-459-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-14
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3999225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant