Basic Information
| Provider Information | |||||||||
| NPI: | 1588064869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | CAITLIN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BARTOL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105218970 | ||||||||
| FaxNumber: | 6105213983 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 BARTOL AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RIDLEY PARK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190782214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105218970 | ||||||||
| FaxNumber: | 6105213983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2014 | ||||||||
| LastUpdateDate: | 02/08/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | MA057053 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.