Provider Demographics
NPI:1811627409
Name:MOORE, MICHAEL HOWARD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:HOWARD
Last Name:MOORE
Suffix:
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 1:501 20TH ST STE 606
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1863
Mailing Address - Country:US
Mailing Address - Phone:865-331-2278
Mailing Address - Fax:
Practice Address - Street 1:10820 PARKSIDE DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1956
Practice Address - Country:US
Practice Address - Phone:865-218-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN216342163W00000X
TN32660367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse