Provider Demographics
NPI:1730153438
Name:MOORE, JOHANNA L (PAC)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:JOHANNA
Other - Middle Name:L
Other - Last Name:CRONAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 3012
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804
Mailing Address - Country:US
Mailing Address - Phone:800-456-4629
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:130 S BRYN MAWR AVE
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010
Practice Address - Country:US
Practice Address - Phone:610-526-3583
Practice Address - Fax:610-526-3614
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA002613L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P14601Medicare UPIN
PA074971Medicare ID - Type Unspecified