Basic Information
| Provider Information | |||||||||
| NPI: | 1881701308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YODER | ||||||||
| OtherFirstName: | PAMELA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ANP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836792 | ||||||||
| FaxNumber: | 2173834752 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | CARDIOLOGY | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2179047000 | ||||||||
| FaxNumber: | 2179047742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 05/28/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | RN81005 | AZ | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 363LA2200X | 209-006880 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 103086 | 01 | MC COCHISE | OTHER | 300051634 | 01 | MARICOPA FOUND | OTHER | 448664 | 01 | MERCY CARE | OTHER | 103087 | 01 | AZ | RR MC PIN | OTHER | 103087 | 01 | MC PIMA | OTHER | 1Z1408 | 01 | INTERGROUP HEALTHNET | OTHER | 300051634 | 01 | HUMANA | OTHER | 448664 | 01 | AHCCCS | OTHER | AZ0819900 | 01 | AZ | BCBS | OTHER | 300051634 | 01 | AZ | HEALTH PLAN AHP | OTHER | 300051634 | 01 | CIGNA | OTHER | 102542 | 01 | AZ | RR MC GRP | OTHER | 103086 | 01 | AZ | RR MC PIN | OTHER | 500005593 | 01 | TRAVELERS MC | OTHER | 300051634 | 01 | AETNA | OTHER | 448664 | 01 | INDIAN HEALTH | OTHER | 448664 | 05 | AZ | MEDICAID |