Basic Information
| Provider Information | |||||||||
| NPI: | 1144662248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE STUCK | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | KAITLIN | ||||||||
| OtherMiddleName: | B | ||||||||
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| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 410 W 10TH AVENUE | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6142938487 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5151 REED RD STE 225C | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432202553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148840641 | ||||||||
| FaxNumber: | 6148840776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | 34012765 | OH | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.