Provider Demographics
NPI:1295778504
Name:MOORE, MEGHAN EMILY (PA)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:EMILY
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:525 BROADWAY
Mailing Address - Street 2:SUITE 1101
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2478
Mailing Address - Country:US
Mailing Address - Phone:310-500-2045
Mailing Address - Fax:323-305-7149
Practice Address - Street 1:525 BROADWAY
Practice Address - Street 2:SUITE 1101
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2478
Practice Address - Country:US
Practice Address - Phone:310-500-2045
Practice Address - Fax:323-305-7149
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA 00346363A00000X
NY012972363A00000X
CAPA19797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant