Provider Demographics
NPI:1508591801
Name:MOORE, BETHANY (AGACNP-C)
Entity Type:Individual
Prefix:MS
First Name:BETHANY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:AGACNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6614 NELSON ST
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80004-1483
Mailing Address - Country:US
Mailing Address - Phone:720-891-3074
Mailing Address - Fax:
Practice Address - Street 1:11700 W 2ND PL
Practice Address - Street 2:MOB 2 STE 210
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1716
Practice Address - Country:US
Practice Address - Phone:720-321-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0997747363LA2200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health