MEDICARE: SHERI A. MOORE LSA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	SA0047	TX
2	363AS0400X	Surgical Physician Assistant	SA0047	TX
3	208600000X	Surgery Physician	SA00047	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0062JR	OTHER	TX	BLUE CROSS & BLUE SHIELD
2	208600000X	OTHER	TX	TAXONOMY

General Provider Information

NPI Number	:	1861564387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERI A. MOORE LSA

Provider Business Mailing Address
First Line	:	PO BOX 40307
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704
Country	:	US
Telephone Number	:	806-787-7840
Fax Number	:	806-794-0125

Provider Business Practice Location Address
First Line	:	910 BUNTON LN
Second Line	:
City	:	UHLAND
State	:	TX
Zip	:	78640-6404
Country	:	US
Telephone Number	:	806-787-7840
Fax Number	:	806-794-0125

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	08/01/2013

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