Provider Demographics
NPI:1467617407
Name:MOORE, SUSAN JOANA (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:JOANA
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 KUENZLI ST STE 202
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-0837
Mailing Address - Country:US
Mailing Address - Phone:775-982-4590
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:975 RYLAND ST STE 100
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1669
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-5225
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001004363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1467617407Medicaid
12215917OtherCAQH
12215917OtherCAQH
NVV109480Medicare PIN
NVV109479Medicare PIN