Provider Demographics
NPI:1366412843
Name:MOORE, JODI (PA-C)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 8TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3951
Mailing Address - Country:US
Mailing Address - Phone:701-456-3819
Mailing Address - Fax:701-456-3815
Practice Address - Street 1:47 8TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3951
Practice Address - Country:US
Practice Address - Phone:701-456-3819
Practice Address - Fax:701-456-3815
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDP00074851OtherRAILROAD MEDICARE
NDP00074851OtherRAILROAD MEDICARE
NDQ09456Medicare UPIN