Provider Demographics
NPI:1558946236
Name:MOORE, WILLIAM MARSHALL IV
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARSHALL
Last Name:MOORE
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6210 E HWY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-1142
Mailing Address - Country:US
Mailing Address - Phone:512-483-9596
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:4100 EVERETT DR STE 400
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6147
Practice Address - Country:US
Practice Address - Phone:512-295-1333
Practice Address - Fax:512-406-7327
Is Sole Proprietor?:No
Enumeration Date:2021-03-14
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1022616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily