Healthcare Provider Details

I. General information

NPI: 1447046503
Provider Name (Legal Business Name): CAMERON JORDAN MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2025
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 ROSS CLARK CIR
DOTHAN AL
36301-3022
US

IV. Provider business mailing address

1305 JJ WHITAKER RD
BONIFAY FL
32425-6323
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-8111
  • Fax:
Mailing address:
  • Phone: 850-768-3819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3-002354
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: