Basic Information
Provider Information | |||||||||
NPI: | 1790853422 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | BERNARD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1535 | ||||||||
Address2: |   | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984011535 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2537614200 | ||||||||
FaxNumber: | 2533833553 | ||||||||
Practice Location | |||||||||
Address1: | 1304 FAWCETT AVE | ||||||||
Address2: | SUITE 100 | ||||||||
City: | TACOMA | ||||||||
State: | WA | ||||||||
PostalCode: | 984021911 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2537614200 | ||||||||
FaxNumber: | 2533833553 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2006 | ||||||||
LastUpdateDate: | 01/31/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10005095 | WA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA10005095 | WA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 0215666 | 01 | WA | LABOR AND INDUSTRIES-TRA | OTHER | 8862653 | 01 | WA | MEDICARE PIN-TRA KING | OTHER | 8943157 | 01 | WA | LABOR AND INDUSTRIES CRIME VICTIMS-TRA | OTHER | P00428602 | 01 | WA | RR MEDICARE-TRA | OTHER | 8862652 | 01 | WA | MEDICARE PIN-TRA PIERCE | OTHER | 8862654 | 01 | WA | MEDICARE PIN-UNION AVENUE OPEN MRI | OTHER | 0249530 | 01 | WA | LABOR AND INDUSTRIES-MEDICAL IMAGING ON 1ST | OTHER | 8951854 | 01 | WA | LABOR AND INDUSTRIES CRIME VICTIMS-MEDICAL IMAGING ON 1ST | OTHER |