Provider Demographics
NPI:1265672141
Name:MOORE, REGINA LYNNE (RPA/RA)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:LYNNE
Last Name:MOORE
Suffix:
Gender:F
Credentials:RPA/RA
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 504
Mailing Address - Street 2:
Mailing Address - City:DONIPHAN
Mailing Address - State:MO
Mailing Address - Zip Code:63935-0504
Mailing Address - Country:US
Mailing Address - Phone:573-996-2669
Mailing Address - Fax:573-996-2669
Practice Address - Street 1:RR 3 BOX 4244
Practice Address - Street 2:
Practice Address - City:DONIPHAN
Practice Address - State:MO
Practice Address - Zip Code:63935-8473
Practice Address - Country:US
Practice Address - Phone:573-996-2669
Practice Address - Fax:573-996-2669
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-04
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO06MO1254243U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant