Provider Demographics
NPI:1134173800
Name:MOORE, WILLIAM A (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:A
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WILMINGTON CIR
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-9311
Mailing Address - Country:US
Mailing Address - Phone:575-749-1739
Mailing Address - Fax:575-760-3562
Practice Address - Street 1:1 MT CARMEL WAY
Practice Address - Street 2:
Practice Address - City:PITTSBURG
Practice Address - State:KS
Practice Address - Zip Code:66762-7587
Practice Address - Country:US
Practice Address - Phone:620-231-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-46260207V00000X
WY14510A207V00000X
OK39319207V00000X
NM91-266207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25865Medicaid
NM25865Medicaid