Provider Demographics
NPI:1235769258
Name:MOORE, HASANI
Entity Type:Individual
Prefix:
First Name:HASANI
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 1:4140 REDWOOD HWY STE 7
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2727
Mailing Address - Country:US
Mailing Address - Phone:415-889-7885
Mailing Address - Fax:
Practice Address - Street 1:250 BON AIR RD UNIT B
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-473-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-17
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty