Provider Demographics
NPI:1144255225
Name:MOORE, JIMMIE G JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:G
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:3688 VETERANS MEMORIAL DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8246
Mailing Address - Country:US
Mailing Address - Phone:601-554-7400
Mailing Address - Fax:601-554-7488
Practice Address - Street 1:3688 VETERANS MEMORIAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8246
Practice Address - Country:US
Practice Address - Phone:601-554-7400
Practice Address - Fax:601-554-7488
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MSPA028363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02274715Medicaid
MS970000013Medicare ID - Type Unspecified
MS02274715Medicaid