Provider Demographics
NPI:1710971908
Name:MORAN, JUDITH ANNE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ANNE
Last Name:MORAN
Suffix:
Gender:F
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:PO BOX 22407
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63126-0407
Mailing Address - Country:US
Mailing Address - Phone:636-386-7222
Mailing Address - Fax:636-386-7810
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:636-386-7222
Practice Address - Fax:636-386-7810
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC01016367500000X
TNAPN0000010072367500000X
MO128948367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR143653701Medicaid
TN4068895OtherBLUE CROSS TN PROV #
TN3629651Medicaid
MO911331007Medicaid
MO900418777OtherRR MEDICARE
AR5T743OtherBLUE CROSS AR PROV #
AR143653701Medicaid
MO831090276Medicare PIN
TN3629654Medicare ID - Type UnspecifiedTN MEDICARE PROVIDER #