Provider Demographics
NPI:1174692347
Name:MOORE, ROBIN R (PAC)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:R
Last Name:MOORE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-8578
Mailing Address - Country:US
Mailing Address - Phone:425-502-3000
Mailing Address - Fax:
Practice Address - Street 1:11511 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-8578
Practice Address - Country:US
Practice Address - Phone:425-502-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUS7195615OtherAETNA SPECIALIST PIN
WA8371296Medicaid
WAP00265426OtherRAILROAD MC#
WA0039581OtherLABOR AND INDUSTRIES #
WA2681MOOtherBLUE SHIELD #
WA8371296Medicaid
WAP00265426OtherRAILROAD MC#
WAGAB40008Medicare PIN