Provider Demographics
NPI:1295793099
Name:MOORE, ROGER L (PA)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22063
Mailing Address - Street 2:DEPT 0289
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-2063
Mailing Address - Country:US
Mailing Address - Phone:405-751-4664
Mailing Address - Fax:405-749-4561
Practice Address - Street 1:2929 S GARNETT RD
Practice Address - Street 2:C/O MEDCENTER
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-5101
Practice Address - Country:US
Practice Address - Phone:918-665-1520
Practice Address - Fax:405-749-4561
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1378363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200050070AMedicaid
OK244506701Medicare PIN
OK200050070AMedicaid
OK24H619027Medicare PIN
OK24H620533Medicare PIN
OKQ37389Medicare UPIN