Provider Demographics
NPI:1447580139
Name:MOORE, SAMUEL AUSTIN (CRNA)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:AUSTIN
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 1:823 SW MULVANE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66606-1764
Mailing Address - Country:US
Mailing Address - Phone:785-235-3451
Mailing Address - Fax:
Practice Address - Street 1:823 SW MULVANE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1764
Practice Address - Country:US
Practice Address - Phone:785-235-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-03
Last Update Date:2010-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-93244-062367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered