Provider Demographics
NPI:1346575081
Name:MOORE, NATHAN THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:THOMAS
Last Name:MOORE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:623-537-5600
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:140 N LITCHFIELD RD STE 110
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-1226
Practice Address - Country:US
Practice Address - Phone:602-256-2525
Practice Address - Fax:602-256-0795
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.003264390200000X
AZ006433207XS0114X, 174400000X, 207X00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ916205Medicaid
AZ916205Medicaid