Provider Demographics
NPI:1649835521
Name:MOORE, JAMES LEROY
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:LEROY
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5010 WOOD SHIRE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-6654
Mailing Address - Country:US
Mailing Address - Phone:816-674-5528
Mailing Address - Fax:
Practice Address - Street 1:5010 WOOD SHIRE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-6654
Practice Address - Country:US
Practice Address - Phone:816-674-5528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113646207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO113646OtherATHLETIC TRAINER