Healthcare Provider Details

I. General information

NPI: 1013550383
Provider Name (Legal Business Name): NICHOLAS MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2019
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S MILL AVE
TEMPE AZ
85281-6699
US

IV. Provider business mailing address

912 GRANGER FARM WAY
LAS VEGAS NV
89145-8618
US

V. Phone/Fax

Practice location:
  • Phone: 480-784-5500
  • Fax:
Mailing address:
  • Phone: 808-387-4316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA95001207
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number834330
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number246503
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: