Provider Demographics
NPI:1275549040
Name:MOORE, JERRIE G (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRIE
Middle Name:G
Last Name:MOORE
Suffix:
Gender:F
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 5165
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76307
Mailing Address - Country:US
Mailing Address - Phone:940-723-1441
Mailing Address - Fax:940-766-3659
Practice Address - Street 1:1105 BROOK
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301
Practice Address - Country:US
Practice Address - Phone:940-723-1441
Practice Address - Fax:940-766-3659
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX035390367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX81708CMedicare PIN