Basic Information
Provider Information | |||||||||
NPI: | 1063882231 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | EDELMIRA | ||||||||
MiddleName: | APRIL | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TIMMONS | ||||||||
OtherFirstName: | EDELMIRA | ||||||||
OtherMiddleName: | APRIL | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 99 HIGHWAY 37 W | ||||||||
Address2: |   | ||||||||
City: | TOMS RIVER | ||||||||
State: | NJ | ||||||||
PostalCode: | 087556423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7325578000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 99 HIGHWAY 37 W | ||||||||
Address2: |   | ||||||||
City: | TOMS RIVER | ||||||||
State: | NJ | ||||||||
PostalCode: | 087556423 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2024600340 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2015 | ||||||||
LastUpdateDate: | 07/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 25 MP00378900 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 0110- 004962 | VA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 25MP00378900 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.