Provider Demographics
NPI:1710936208
Name:MOORE, JANE ANN (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:ANN
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:ANN
Other - Last Name:BALDERSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6002 WESTGATE BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-2571
Mailing Address - Country:US
Mailing Address - Phone:253-759-9902
Mailing Address - Fax:253-759-5504
Practice Address - Street 1:6002 WESTGATE BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2571
Practice Address - Country:US
Practice Address - Phone:253-759-9902
Practice Address - Fax:253-759-5504
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020608208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1105436Medicaid
WAM07731OtherREGENCE
WA1105436Medicaid
A06050Medicare UPIN