Healthcare Provider Details

I. General information

NPI: 1104219005
Provider Name (Legal Business Name): THOMAS BRENT MOORE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 BANNOCK ST
DENVER CO
80204-4507
US

IV. Provider business mailing address

1226 ELIZABETH ST
DENVER CO
80206-3220
US

V. Phone/Fax

Practice location:
  • Phone: 601-434-3303
  • Fax:
Mailing address:
  • Phone: 601-434-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPN.0991600-CRNA
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: