Provider Demographics
NPI:1821529652
Name:MOORE, JONATHAN ALAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ALAN
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 1:9250 N 3RD ST STE 2030
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9250 N 3RD ST STE 2030
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2407
Practice Address - Country:US
Practice Address - Phone:602-786-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-23
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302603207R00000X
390200000X
AZ70643207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty