Healthcare Provider Details

I. General information

NPI: 1689086837
Provider Name (Legal Business Name): THOMAS MOORE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 02/10/2023
Certification Date: 02/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 CANTON ST SUITE 325
WESTWOOD MA
02090-2321
US

IV. Provider business mailing address

333 CEDAR ST TMP 3
NEW HAVEN CT
06510
US

V. Phone/Fax

Practice location:
  • Phone: 781-407-7713
  • Fax: 781-407-0998
Mailing address:
  • Phone: 203-785-2802
  • Fax: 203-785-6664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6951
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number283089
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: