Provider Demographics
NPI:1134700941
Name:MOORE, STANLEY JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:JOSEPH
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 1:14716 NE 40TH ST APT S1006
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3333
Mailing Address - Country:US
Mailing Address - Phone:360-649-8708
Mailing Address - Fax:
Practice Address - Street 1:819 S 13TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4112
Practice Address - Country:US
Practice Address - Phone:360-814-6230
Practice Address - Fax:360-814-6240
Is Sole Proprietor?:No
Enumeration Date:2021-04-14
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML61170278390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program