Provider Demographics
NPI:1760212195
Name:PATE-MOORE, CASSIDY BOONE
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:BOONE
Last Name:PATE-MOORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 S 17TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7593
Mailing Address - Country:US
Mailing Address - Phone:910-763-3333
Mailing Address - Fax:910-799-2943
Practice Address - Street 1:2208 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7593
Practice Address - Country:US
Practice Address - Phone:910-763-3333
Practice Address - Fax:910-799-2943
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-01
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant