1710936208 NPI number — JANE ANN MOORE MD

Table of content: JANE ANN MOORE MD (NPI 1710936208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710936208 NPI number — JANE ANN MOORE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
JANE
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALDERSTON
Provider Other First Name:
JANE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710936208
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6002 WESTGATE BLVD
Provider Second Line Business Mailing Address:
SUITE 160
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98406-2571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-759-9902
Provider Business Mailing Address Fax Number:
253-759-5504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6002 WESTGATE BLVD
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98406-2571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-759-9902
Provider Business Practice Location Address Fax Number:
253-759-5504
Provider Enumeration Date:
05/10/2006

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: 208D00000X , with the licence number:  MD00020608 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1105436 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: M07731 . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com