Provider Demographics
NPI:1700476405
Name:MOORE, EDWARD RYAN (RN, CRNP)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RYAN
Last Name:MOORE
Suffix:
Gender:M
Credentials:RN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 SADDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PIKE ROAD
Mailing Address - State:AL
Mailing Address - Zip Code:36064-2736
Mailing Address - Country:US
Mailing Address - Phone:334-315-4813
Mailing Address - Fax:
Practice Address - Street 1:454 TAYLOR RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3563
Practice Address - Country:US
Practice Address - Phone:334-613-9000
Practice Address - Fax:334-532-0056
Is Sole Proprietor?:No
Enumeration Date:2021-01-26
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-163024163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse