Provider Demographics
NPI:1437430055
Name:MOORE, THOMAS G
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
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 1:2510 E SUNSET RD
Mailing Address - Street 2:UNIT 5-260
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3511
Mailing Address - Country:US
Mailing Address - Phone:702-798-0113
Mailing Address - Fax:866-291-5242
Practice Address - Street 1:3301 MENAUL BLVD NE
Practice Address - Street 2:SUITE 26
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-1852
Practice Address - Country:US
Practice Address - Phone:505-889-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
NM4981237700000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNMAAA2144Medicare PIN