Provider Demographics
NPI:1831064500
Name:MOORE, ETHAN
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:MOORE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9707 NINA ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3750
Mailing Address - Country:US
Mailing Address - Phone:308-991-6136
Mailing Address - Fax:
Practice Address - Street 1:9707 NINA ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68124-3750
Practice Address - Country:US
Practice Address - Phone:308-991-6136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-10
Last Update Date:2025-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion