Basic Information
| Provider Information | |||||||||
| NPI: | 1912988650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 209 LILLY RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604138250 | ||||||||
| FaxNumber: | 3604138830 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 LILLY RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604138250 | ||||||||
| FaxNumber: | 3604138830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 04/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA10003474 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MM0256861 | 01 | WA | DEA NUMBER | OTHER | PA10003474 | 01 | WA | PA LISENCE | OTHER |