Provider Demographics
NPI:1902432644
Name:MOORE, MADISON ALEXIS (PA-C)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ALEXIS
Last Name:MOORE
Suffix:
Gender:F
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 1:24603 E OAKLAND RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-2753
Mailing Address - Country:US
Mailing Address - Phone:440-915-4084
Mailing Address - Fax:
Practice Address - Street 1:36701 AMERICAN WAY STE 3
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:OH
Practice Address - Zip Code:44011-4064
Practice Address - Country:US
Practice Address - Phone:440-937-4951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-13
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007933RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical