Individual
MS. BRANDI N MOORE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
245 FORT CHISWELL RD STE D, MAX MEADOWS, VA 24360-3987
(276) 613-6991
Mailing address
1123 POWDER MILL RD, IVANHOE, VA 24350-3559
(276) 699-0105
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
0110-002204
VA
363A00000X
Physician Assistant
Primary
0110-002204
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
010220793
—
VA
05
—
010220807
—
VA
05
—
10220815
—
VA
01
—
1068476
NCCPA CERTIFICATE NUMBER
VA
Enumeration date
11/25/2005
Last updated
01/11/2022
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