Provider Demographics
NPI:1437305042
Name:MOORE, GARY JOHN (RN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JOHN
Last Name:MOORE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 NYE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9133
Mailing Address - Country:US
Mailing Address - Phone:315-946-5749
Mailing Address - Fax:315-946-5767
Practice Address - Street 1:1519 NYE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9133
Practice Address - Country:US
Practice Address - Phone:315-946-5749
Practice Address - Fax:315-946-5767
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229602163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health