Provider Demographics
NPI:1013550383
Name:MOORE, NICHOLAS
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 GRANGER FARM WAY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-8618
Mailing Address - Country:US
Mailing Address - Phone:808-387-4316
Mailing Address - Fax:
Practice Address - Street 1:1500 S MILL AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-6699
Practice Address - Country:US
Practice Address - Phone:480-784-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-19
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA95001207367500000X
NV834330367500000X
AZ246503367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered