Basic Information
| Provider Information | |||||||||
| NPI: | 1821049206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | QADARA | ||||||||
| MiddleName: | FARIH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037776508 | ||||||||
| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065133733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037776508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 11/18/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001633 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 012904 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 6543809 | 01 | NY | NEW YORK STATE (CERTIFICATE NUMBER) | OTHER | MM1291614 | 01 | DEA REGISTRATION | OTHER | 1066955 | 01 | NCCPA CERTIFICATION | OTHER | 012904 | 01 | NY | NEW YORK STATE (LICENSE NUMBER) | OTHER | 11485065 | 01 | CT | CAQH | OTHER | 38064 | 01 | CT | CONNECTICUT CONNECTICUT CONTROLLED SUBSTANCE | OTHER |