Provider Demographics
NPI:1528382728
Name:MOORE, ADAM WAYNE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:WAYNE
Last Name:MOORE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13249 KOMATITE WAY
Mailing Address - Street 2:UNIT 500
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-5441
Mailing Address - Country:US
Mailing Address - Phone:812-236-5250
Mailing Address - Fax:
Practice Address - Street 1:5949 W RAYMOND ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-4348
Practice Address - Country:US
Practice Address - Phone:317-247-1579
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001519A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer