Provider Demographics
NPI:1407893456
Name:MOORE, TREVENA (MD)
Entity Type:Individual
Prefix:
First Name:TREVENA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 OLATHE BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING OFFICE
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160
Mailing Address - Country:US
Mailing Address - Phone:913-588-5746
Mailing Address - Fax:
Practice Address - Street 1:2000 OLATHE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-1003
Practice Address - Country:US
Practice Address - Phone:913-588-5746
Practice Address - Fax:913-274-3546
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003012943208000000X
KS04-402732080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics