Basic Information
| Provider Information | |||||||||
| NPI: | 1104971266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | NATASHA | ||||||||
| MiddleName: | PUGH | ||||||||
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| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PUGH MOORE | ||||||||
| OtherFirstName: | NATASHA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2727 W DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133507244 | ||||||||
| FaxNumber: | 8133507246 | ||||||||
| Practice Location | |||||||||
| Address1: | 2727 W DR MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133507244 | ||||||||
| FaxNumber: | 8133507246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2007 | ||||||||
| LastUpdateDate: | 08/28/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 176958 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 0024168116 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | ARNP9370840 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P00272494 | 01 | NC | RAILROAD-MEDICARE | OTHER | 12367790 | 01 | CAQH | OTHER | 8052135 | 05 | NC | MEDICAID |