Provider Demographics
NPI:1821607052
Name:MOORE, COLTON RAY (APRN, FNP-C)
Entity Type:Individual
Prefix:MR
First Name:COLTON
Middle Name:RAY
Last Name:MOORE
Suffix:
Gender:M
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E REELFOOT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-6049
Mailing Address - Country:US
Mailing Address - Phone:901-350-0978
Mailing Address - Fax:901-350-0677
Practice Address - Street 1:1720 E REELFOOT AVE STE 200
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-6049
Practice Address - Country:US
Practice Address - Phone:901-350-0978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-23
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27851363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily