Provider Demographics
NPI:1215008891
Name:MOORE, MICHAEL J (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 4450
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-4450
Mailing Address - Country:US
Mailing Address - Phone:605-622-5000
Mailing Address - Fax:605-622-5255
Practice Address - Street 1:305 S STATE ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4527
Practice Address - Country:US
Practice Address - Phone:605-622-5000
Practice Address - Fax:605-622-5255
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR025845367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR35918OtherDAKOTACARE
SD0002489OtherBLUE CROSS
SD035918OtherCRNA CERTIFICATION
SD5752422Medicaid
SD035918OtherCRNA CERTIFICATION