Provider Demographics
NPI:1225109556
Name:MOORE, DEBRA S (CRNA)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:S
Last Name:MOORE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:S
Other - Last Name:GALLAGHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18167 US HIGHWAY 19 N STE 650
Mailing Address - Street 2:CREDENTIALS DEPT
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33764-6576
Mailing Address - Country:US
Mailing Address - Phone:727-437-0836
Mailing Address - Fax:
Practice Address - Street 1:21260 OLEAN BLVD
Practice Address - Street 2:STE 105
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6742
Practice Address - Country:US
Practice Address - Phone:941-235-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN320754L367500000X
FLARNP9382294367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA107415Medicare PIN