Provider Demographics
NPI:1326356650
Name:MOORE, ANTONIO D (CRNA)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:D
Last Name:MOORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:129 W LAKE MEAD PKWY
Mailing Address - Street 2:#B-18
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7055
Mailing Address - Country:US
Mailing Address - Phone:702-564-4440
Mailing Address - Fax:702-558-1522
Practice Address - Street 1:6728 E GRANDVIEW DR
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-5668
Practice Address - Country:US
Practice Address - Phone:702-564-4440
Practice Address - Fax:702-558-1522
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZCRNA0763367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ615765Medicaid
NVDV688ZMedicare PIN