Provider Demographics
NPI:1144210188
Name:MOORE, MARK GREGORY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:GREGORY
Last Name:MOORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2127
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-7127
Mailing Address - Country:US
Mailing Address - Phone:903-677-1000
Mailing Address - Fax:903-677-5586
Practice Address - Street 1:2000 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-5610
Practice Address - Country:US
Practice Address - Phone:903-677-1000
Practice Address - Fax:903-677-5586
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX548063367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0026460-01Medicaid
TX0026460-01Medicaid
R69618Medicare UPIN
81916HMedicare PIN