Provider Demographics
NPI:1558396697
Name:MOYER, BRIAN W (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:MOYER
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 1:11110 MEDICAL CAMPUS ROAD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742
Mailing Address - Country:US
Mailing Address - Phone:301-714-4300
Mailing Address - Fax:301-714-4324
Practice Address - Street 1:11110 MEDICAL CAMPUS ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742
Practice Address - Country:US
Practice Address - Phone:301-714-4300
Practice Address - Fax:301-714-4324
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR087438207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD590041700Medicaid
MD590041700Medicaid