Provider Demographics
NPI:1508106469
Name:MOORE, MICHAEL ALAN (RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ALAN
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 1:2631 CLAYTON DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-2423
Mailing Address - Country:US
Mailing Address - Phone:248-622-7067
Mailing Address - Fax:
Practice Address - Street 1:38251 S GROESBECK HWY
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48036-1929
Practice Address - Country:US
Practice Address - Phone:586-469-6210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-28
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222093163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse