Provider Demographics
NPI:1346316932
Name:MOORE, RYAN MARY (NP)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:MARY
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42575 WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92211-8850
Mailing Address - Country:US
Mailing Address - Phone:760-360-0333
Mailing Address - Fax:760-360-1053
Practice Address - Street 1:42575 WASHINGTON
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-8850
Practice Address - Country:US
Practice Address - Phone:760-360-0333
Practice Address - Fax:760-360-1053
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP14225363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NP14225Medicare ID - Type Unspecified