Provider Demographics
NPI:1265180871
Name:MOORE, KEVIN PHILLIP
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PHILLIP
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 DICKSON ST
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-4533
Mailing Address - Country:US
Mailing Address - Phone:585-943-8333
Mailing Address - Fax:
Practice Address - Street 1:169 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13905-4246
Practice Address - Country:US
Practice Address - Phone:607-798-5231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-13
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant