Healthcare Provider Details

I. General information

NPI: 1235378423
Provider Name (Legal Business Name): JOEL M MOORE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 02/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 CUDE LN
MADISON TN
37115-2202
US

IV. Provider business mailing address

154 CUDE LN
MADISON TN
37115-2202
US

V. Phone/Fax

Practice location:
  • Phone: 615-865-6268
  • Fax: 615-868-7378
Mailing address:
  • Phone: 615-865-6268
  • Fax: 615-868-7378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number13847
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: