Basic Information
| Provider Information | |||||||||
| NPI: | 1750858916 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 SEYMOUR STREET | ||||||||
| Address2: | HARTFORD HOSPITAL MEDICINE DEPT | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061025037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609722085 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12605 E 16TH AVE | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800452545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037242728 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2018 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 004400 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 004400 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363AS0400X | PA.0007220 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.