Provider Demographics
NPI:1902325681
Name:MOORE, JASON ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ANTHONY
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13861 PLANTATION RD STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4342
Mailing Address - Country:US
Mailing Address - Phone:239-225-1306
Mailing Address - Fax:239-768-1313
Practice Address - Street 1:13861 PLANTATION RD STE 104
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4342
Practice Address - Country:US
Practice Address - Phone:239-225-1306
Practice Address - Fax:239-768-1313
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPAT9110628363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical