Provider Demographics
NPI:1326122540
Name:MOORE, JAMES R (MT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:MOORE
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 NESPELEM/SANPOIL ST
Mailing Address - Street 2:
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155-0071
Mailing Address - Country:US
Mailing Address - Phone:509-634-2900
Mailing Address - Fax:509-634-2945
Practice Address - Street 1:29 NESPELEM/SANPOIL ST
Practice Address - Street 2:
Practice Address - City:NESPELEM
Practice Address - State:WA
Practice Address - Zip Code:99155-0071
Practice Address - Country:US
Practice Address - Phone:509-634-2900
Practice Address - Fax:509-634-2945
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7100100Medicaid
WA7100100Medicaid