Healthcare Provider Details

I. General information

NPI: 1053418921
Provider Name (Legal Business Name): MARTHA JANE MOORE MD-MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: M JANE MOORE MD-MPH

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3223 E PALMER WASILLA HWY STE 4
WASILLA AK
99654-7277
US

IV. Provider business mailing address

3223 E PALMER WASILLA HWY STE 4
WASILLA AK
99654-7277
US

V. Phone/Fax

Practice location:
  • Phone: 907-631-6300
  • Fax: 907-631-6314
Mailing address:
  • Phone: 907-631-6300
  • Fax: 907-631-6314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number6678
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3944
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierMD8920
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: