Provider Demographics
NPI:1134842172
Name:MOORE, JONATHAN KURTIS (CRNA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KURTIS
Last Name:MOORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 W STERLING RD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:OH
Mailing Address - Zip Code:44214-9562
Mailing Address - Country:US
Mailing Address - Phone:330-749-9474
Mailing Address - Fax:
Practice Address - Street 1:4315 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5926
Practice Address - Country:US
Practice Address - Phone:907-563-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK197941163W00000X
OH439888163W00000X
AK199497367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered Nurse