Healthcare Provider Details

I. General information

NPI: 1407858160
Provider Name (Legal Business Name): BEVERLY D MOYER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 N MOUNTAIN BLVD
MOUNTAIN TOP PA
18707-1117
US

IV. Provider business mailing address

56 N MOUNTAIN BLVD
MOUNTAIN TOP PA
18707-1117
US

V. Phone/Fax

Practice location:
  • Phone: 570-474-1130
  • Fax: 570-474-1174
Mailing address:
  • Phone: 570-474-1130
  • Fax: 570-474-1174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN163804
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: