Provider Demographics
NPI:1407293699
Name:MOORE, TIMOTHY ALLEN (CRNA)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:MOORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6818 E LOOKOUT DR
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-8709
Mailing Address - Country:US
Mailing Address - Phone:720-318-7764
Mailing Address - Fax:
Practice Address - Street 1:2350 MEADOWS BLVD
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80109-8405
Practice Address - Country:US
Practice Address - Phone:720-455-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0165348163W00000X
COAPN.0990803-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26870576Medicaid