Basic Information
| Provider Information | |||||||||
| NPI: | 1013099068 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | ANGELO | ||||||||
| MiddleName: | DEWITT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 MILLENNIUM LOOP | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103094337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186304186 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1075 STEPHENSON AVE | ||||||||
| Address2: | PATTERSON ARMY HEALTH CLINIC | ||||||||
| City: | FORT MONMOUTH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325320182 | ||||||||
| FaxNumber: | 7325320194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 138235 | NC | X | Nursing Service Providers | Registered Nurse | 363LF0000X | 648115 | TX | X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.