Provider Demographics
NPI:1760717797
Name:MOORE, GASTON A JR (LPN)
Entity Type:Individual
Prefix:MR
First Name:GASTON
Middle Name:A
Last Name:MOORE
Suffix:JR
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 W TUCKEY LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-1715
Mailing Address - Country:US
Mailing Address - Phone:602-518-5910
Mailing Address - Fax:
Practice Address - Street 1:1702 W TUCKEY LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-1715
Practice Address - Country:US
Practice Address - Phone:602-518-5910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP039366164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLP039366OtherLPN