Basic Information
| Provider Information | |||||||||
| NPI: | 1447227285 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4190 | ||||||||
| Address2: | |||||||||
| City: | BARBOURSVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255044190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043994405 | ||||||||
| FaxNumber: | 3043992526 | ||||||||
| Practice Location | |||||||||
| Address1: | 2828 1ST AVE | ||||||||
| Address2: | SUITE 510 | ||||||||
| City: | HUNTINGTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 257021236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043997533 | ||||||||
| FaxNumber: | 3043997507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2006 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 4411P | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 50644 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100008460 | 05 | KY | MEDICAID | P00892178 | 01 | WV | RR MEDICARE | OTHER | 2654266 | 05 | OH | MEDICAID | 3810004812 | 05 | WV | MEDICAID |