Healthcare Provider Details

I. General information

NPI: 1457970899
Provider Name (Legal Business Name): WILLIAM MORAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2020
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 DAFFODIL RIDGE DR
O FALLON MO
63366-7760
US

IV. Provider business mailing address

910 DAFFODIL RIDGE DR
O FALLON MO
63366-7760
US

V. Phone/Fax

Practice location:
  • Phone: 314-780-2257
  • Fax:
Mailing address:
  • Phone: 314-780-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2014020992
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number083092-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: