Provider Demographics
NPI:1932201357
Name:MOORE, TROY LANCE (MPT, ATC)
Entity Type:Individual
Prefix:MR
First Name:TROY
Middle Name:LANCE
Last Name:MOORE
Suffix:
Gender:M
Credentials:MPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 K 96 HWY
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3012
Mailing Address - Country:US
Mailing Address - Phone:620-792-7868
Mailing Address - Fax:620-792-7867
Practice Address - Street 1:1514 K 96 HWY
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67526-3012
Practice Address - Country:US
Practice Address - Phone:620-792-7868
Practice Address - Fax:620-792-7867
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-00797225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200400390AMedicaid
KS200400390AMedicaid