Basic Information
| Provider Information | |||||||||
| NPI: | 1730139320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUZZALL-MOORE | ||||||||
| FirstName: | MAURA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3188 | ||||||||
| Address2: | |||||||||
| City: | OMAK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988413188 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098261600 | ||||||||
| FaxNumber: | 5098263633 | ||||||||
| Practice Location | |||||||||
| Address1: | 529 JASMINE ST | ||||||||
| Address2: | |||||||||
| City: | OMAK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988419589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5298261600 | ||||||||
| FaxNumber: | 5098263633 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA10000002975 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 8931006 | 01 | WA | CRIME VICTIM COMPENSATION | OTHER | 5530MU | 01 | WA | ASURIS INSURANCE CO, | OTHER | 8371858 | 05 | WA | MEDICAID | 0176649 | 01 | WA | WORKERS COMPENSATION | OTHER |