Provider Demographics
NPI:1295314268
Name:MOORE, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12067 APPLETON DR
Mailing Address - Street 2:
Mailing Address - City:PARMA HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-4223
Mailing Address - Country:US
Mailing Address - Phone:469-658-6772
Mailing Address - Fax:
Practice Address - Street 1:10553 SAINT CLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44108-1973
Practice Address - Country:US
Practice Address - Phone:216-682-7702
Practice Address - Fax:216-920-6273
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH59.000886213E00000X
OH36.004134213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist