Basic Information
| Provider Information | |||||||||
| NPI: | 1568973576 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34612 6TH AVE S STE 300 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538388552 | ||||||||
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| Practice Location | |||||||||
| Address1: | 34612 6TH AVE S STE 300 | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980038723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538388552 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2017 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA.0777859 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | OA60803041 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2096256 | 05 | WA | MEDICAID |