1912010166 NPI number — MARY MOORE CRNA

Table of content: MARY MOORE CRNA (NPI 1912010166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912010166 NPI number — MARY MOORE CRNA

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912010166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
999 EXECUTIVE PARK BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37660-4632
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-224-3250
Provider Business Mailing Address Fax Number:
423-224-3258

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1980 HOLTON AVE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIG STONE GAP
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24219-3366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-523-3111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2006

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: 367500000X , with the licence number:  0024049167 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 74012436 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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