Healthcare Provider Details

I. General information

NPI: 1255430161
Provider Name (Legal Business Name): BRIAN W MOON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W OTTLEY AVE
FRUITA CO
81521-2118
US

IV. Provider business mailing address

1200 COLLEGE DR
ROCK SPRINGS WY
82901-5868
US

V. Phone/Fax

Practice location:
  • Phone: 970-858-3900
  • Fax: 970-858-2202
Mailing address:
  • Phone: 307-362-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number14820A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG80229
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: