Provider Demographics
NPI:1801937743
Name:MOORE, MARK ROBLEY (CRNA)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ROBLEY
Last Name:MOORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:4150 NELSON RD
Mailing Address - Street 2:ANESTHESIA ASSOCIATES A4
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605
Mailing Address - Country:US
Mailing Address - Phone:337-474-6353
Mailing Address - Fax:337-477-7616
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:ANESTHESIA ASSOCIATES A4
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605
Practice Address - Country:US
Practice Address - Phone:337-474-6353
Practice Address - Fax:337-477-7616
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA45322367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1927244Medicaid
LA1927244Medicaid
LA56336Medicare ID - Type Unspecified