Provider Demographics
NPI:1619222528
Name:MOORE, SHAWN WILLIAM (FNP-C)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:WILLIAM
Last Name:MOORE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 DAWSON COMMONS CIR STE 410
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-6269
Mailing Address - Country:US
Mailing Address - Phone:470-773-6725
Mailing Address - Fax:470-773-6726
Practice Address - Street 1:400 DAWSON COMMONS CIR STE 410
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-6269
Practice Address - Country:US
Practice Address - Phone:470-773-6725
Practice Address - Fax:470-773-6726
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191172163WR0006X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125809IMedicaid
GA003125809LMedicaid
GA01667286OtherAMERIGROUP
GA003125809AMedicaid
GA003125809GMedicaid
GA003125809JMedicaid
GA003125809KMedicaid
GA003125809Medicaid
GA003125809BMedicaid
GA003125809FMedicaid
GA003125809QMedicaid