1184864076 NPI number — DR. ANGELA SUE MOORE DO

Table of content: (NPI 1992767024)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184864076 NPI number — DR. ANGELA SUE MOORE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
ANGELA
Provider Middle Name:
SUE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
D'ANNUNZIO
Provider Other First Name:
ANGELA
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184864076
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3510 N RIDGE ROAD, SUITE 500
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67205
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-881-8180
Provider Business Mailing Address Fax Number:
316-881-8239

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3510 N RIDGE ROAD
Provider Second Line Business Practice Location Address:
SUITE 500
Provider Business Practice Location Address City Name:
WICHITA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
316-881-8180
Provider Business Practice Location Address Fax Number:
316-881-8329
Provider Enumeration Date:
03/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  0534062 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 47165 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200639670A , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1184864076 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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