Healthcare Provider Details

I. General information

NPI: 1609575695
Provider Name (Legal Business Name): TIMOTHY J MOORE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2023
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1152 GREENVIEW RD
COLLIERVILLE TN
38017-1160
US

IV. Provider business mailing address

1152 GREENVIEW RD
COLLIERVILLE TN
38017-1160
US

V. Phone/Fax

Practice location:
  • Phone: 901-674-4636
  • Fax:
Mailing address:
  • Phone: 901-674-4636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number36528
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number901929
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: