Provider Demographics
NPI:1548870934
Name:MOORE, EVAN C (DNP)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:C
Last Name:MOORE
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 HAMMOND ST STE 9998
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-9998
Mailing Address - Country:US
Mailing Address - Phone:480-235-9434
Mailing Address - Fax:
Practice Address - Street 1:73 HAMMOND ST STE 9998
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-9998
Practice Address - Country:US
Practice Address - Phone:480-235-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP211261363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health