Provider Demographics
NPI:1801870480
Name:MOORE, JEFFERY W (CRNA)
Entity type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:W
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 1:1000 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IN
Mailing Address - Zip Code:46072-9753
Mailing Address - Country:US
Mailing Address - Phone:765-675-8521
Mailing Address - Fax:765-675-8520
Practice Address - Street 1:1000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IN
Practice Address - Zip Code:46072-9753
Practice Address - Country:US
Practice Address - Phone:765-675-8521
Practice Address - Fax:765-675-8520
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28087122367H00000X
IN28087122A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200345230AMedicaid
IN200345230Medicaid
IN000000603596OtherANTHEM - TIPTON HOSPITAL
INCC9210AMedicare ID - Type Unspecified
L84631Medicare UPIN
IN260220LMedicare PIN