Provider Demographics
NPI:1134166184
Name:MOORE, NICOLA L (MD)
Entity type:Individual
Prefix:
First Name:NICOLA
Middle Name:L
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
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 4557
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4557
Mailing Address - Country:US
Mailing Address - Phone:866-290-4325
Mailing Address - Fax:515-280-9525
Practice Address - Street 1:1000 E ARMY POST RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-5939
Practice Address - Country:US
Practice Address - Phone:515-280-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA223184207Q00000X
CA89646207Q00000X
IA37992207Q00000X
NE24762207Q00000X
NY219226207Q00000X
IA01898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0057570Medicaid
IAA02049Medicare UPIN
IA0057570Medicaid