Basic Information
| Provider Information | |||||||||
| NPI: | 1619222528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 658 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305030658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707181122 | ||||||||
| FaxNumber: | 7705334786 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 JESSE JEWELL PKWY SE | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305013854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705337288 | ||||||||
| FaxNumber: | 7705349800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2012 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN191172 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 003125809J | 05 | GA | MEDICAID | 003125809 | 05 | GA | MEDICAID | 003125809B | 05 | GA | MEDICAID | 01667286 | 01 | GA | AMERIGROUP | OTHER | 003125809A | 05 | GA | MEDICAID | 003125809I | 05 | GA | MEDICAID |