Provider Demographics
NPI:1578805123
Name:MOORE, RONALD BARRY (FNP-BC, PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:BARRY
Last Name:MOORE
Suffix:
Gender:M
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 MONTICELLO CT
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78665-5021
Mailing Address - Country:US
Mailing Address - Phone:512-535-3777
Mailing Address - Fax:512-765-9153
Practice Address - Street 1:101 W COOPERATIVE WAY STE 110
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-8209
Practice Address - Country:US
Practice Address - Phone:512-535-3777
Practice Address - Fax:512-765-9153
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX555197363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1644Medicaid