Provider Demographics
NPI:1649656380
Name:MOORE, JEREMIAH (CRNA)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
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 1:2341 MCCALLIE AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3231
Mailing Address - Country:US
Mailing Address - Phone:423-698-3309
Mailing Address - Fax:
Practice Address - Street 1:2341 MCCALLIE AVE STE 402
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3231
Practice Address - Country:US
Practice Address - Phone:423-698-3309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20439367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered