Provider Demographics
NPI:1255430161
Name:MOON, BRIAN W (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:W
Last Name:MOON
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 1:1200 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5868
Mailing Address - Country:US
Mailing Address - Phone:307-362-3711
Mailing Address - Fax:
Practice Address - Street 1:300 W OTTLEY AVE
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2118
Practice Address - Country:US
Practice Address - Phone:970-858-3900
Practice Address - Fax:970-858-2202
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY14820A207L00000X
CAG80229207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92855Medicare UPIN