Basic Information
| Provider Information | |||||||||
| NPI: | 1720273295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | IVRY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE PAZDERNIK | ||||||||
| OtherFirstName: | REBECCA | ||||||||
| OtherMiddleName: | IVRY | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3262 | ||||||||
| Address2: | |||||||||
| City: | SEWARD | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996643262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072244916 | ||||||||
| FaxNumber: | 9072245870 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 3RD AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SEWARD | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072244916 | ||||||||
| FaxNumber: | 9072245870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 19315 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PAD A 830 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA19315 | 05 | CA | MEDICAID |