Healthcare Provider Details

I. General information

NPI: 1912798521
Provider Name (Legal Business Name): RYAN WILLIAM MOORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/14/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CROSSINGS BLVD
WARWICK RI
02886-2878
US

IV. Provider business mailing address

30 AUDUBON RD
WARWICK RI
02888-4602
US

V. Phone/Fax

Practice location:
  • Phone: 401-777-7000
  • Fax:
Mailing address:
  • Phone: 401-864-7778
  • Fax: 401-864-7778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCAPRN04584
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: