1710977822 NPI number — MRS. LAURA M MOORE MD

Table of content: MRS. LAURA M MOORE MD (NPI 1710977822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710977822 NPI number — MRS. LAURA M MOORE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOORE
Provider First Name:
LAURA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
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:
ROWLAND
Provider Other First Name:
LAURA
Provider Other Middle Name:
M.
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1710977822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3841 PIPER STREET
Provider Second Line Business Mailing Address:
SUITE T4-054
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99508
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-562-6228
Provider Business Mailing Address Fax Number:
907-562-6868

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3841 PIPER STREET
Provider Second Line Business Practice Location Address:
SUITE T4-054
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-562-6228
Provider Business Practice Location Address Fax Number:
907-562-6868
Provider Enumeration Date:
10/28/2005

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: 207KA0200X , with the licence number:  101511 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 101511 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 12268 . This is a "LICENSE" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".




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