Provider Demographics
NPI:1497989933
Name:MOORE, DAVID B (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:B
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 1:4801 COLLEGE BLVD.
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1628
Mailing Address - Country:US
Mailing Address - Phone:913-491-3999
Mailing Address - Fax:913-491-9309
Practice Address - Street 1:4801 COLLEGE BLVD.
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1628
Practice Address - Country:US
Practice Address - Phone:913-491-3999
Practice Address - Fax:913-491-9309
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-107432-091163W00000X
KS43-556867-091367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200606900BMedicaid
KS139000044Medicare PIN