Provider Demographics
NPI:1386866572
Name:MOORE, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 N STATE ST STE 105
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1354
Mailing Address - Country:US
Mailing Address - Phone:801-655-5245
Mailing Address - Fax:
Practice Address - Street 1:1900 N STATE ST STE 105
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1354
Practice Address - Country:US
Practice Address - Phone:801-655-5245
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8198024-1205207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0722557OtherMEDICARE - FOUNDATION
KY3726872000OtherPASSPORT ADVANTAGE PCP
KY000000610833OtherANTHEM
KY3726871000OtherPASSPORT ADVANTAGE SPECIALITY
KY9328408OtherAETNA
KY3726875000OtherPASSPORT ADVANTAGE
KY7100074130Medicaid
KY50024901OtherPASSPORT SPECIALTY
KY50024902OtherPASSPORT PCP
KY000000610836OtherANTHEM
KY50024905OtherPASSPORT SPECIALITY
IN200947330Medicaid
KY3726871000OtherPASSPORT ADVANTAGE SPECIALITY