Provider Demographics
NPI:1396813598
Name:MOORE, MARSHA ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:MARSHA
Middle Name:ANN
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 1:142 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-3902
Mailing Address - Country:US
Mailing Address - Phone:575-445-2753
Mailing Address - Fax:575-445-2759
Practice Address - Street 1:142 S 1ST ST
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-3902
Practice Address - Country:US
Practice Address - Phone:575-445-2753
Practice Address - Fax:575-445-2759
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR38356363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00071062Medicaid
NM00071062Medicaid