Provider Demographics
NPI:1528028537
Name:MOORE, JOHN A (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
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 1:3501 E SPEEDWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-3917
Mailing Address - Country:US
Mailing Address - Phone:520-833-5171
Mailing Address - Fax:888-395-3034
Practice Address - Street 1:1171 W TARGET RANGE RD
Practice Address - Street 2:
Practice Address - City:NOGALES
Practice Address - State:AZ
Practice Address - Zip Code:85621-2415
Practice Address - Country:US
Practice Address - Phone:520-287-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR53384367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM02373882Medicaid
P00347089OtherRR MEDICARE
Q11684Medicare UPIN
NM02373882Medicaid