Provider Demographics
NPI:1528030244
Name:MOORE, D. WAYNE (PA)
Entity Type:Individual
Prefix:
First Name:D.
Middle Name:WAYNE
Last Name:MOORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 E GEDDES AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-3861
Mailing Address - Country:US
Mailing Address - Phone:303-761-9190
Mailing Address - Fax:303-761-6278
Practice Address - Street 1:501 E HAMPDEN AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2702
Practice Address - Country:US
Practice Address - Phone:303-761-9190
Practice Address - Fax:303-761-6322
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2096207P00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM29404037Medicaid
CO59936363Medicaid
COQ57107Medicare UPIN
COC805887Medicare PIN
NM29404037Medicaid
COC805888Medicare PIN