Provider Demographics
NPI:1073768552
Name:MOORE, TAMMY RENE
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:RENE
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 FOUNTAIN VIEW DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-4817
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:713-458-4229
Practice Address - Street 1:2411 FOUNTAIN VIEW DR
Practice Address - Street 2:SUITE 200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-4817
Practice Address - Country:US
Practice Address - Phone:713-620-4000
Practice Address - Fax:713-458-4229
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX080740367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8074UUOtherBLUE CROSS BLUE SHIELD
TX200866601Medicaid