Basic Information
| Provider Information | |||||||||
| NPI: | 1477711133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7032959360 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 3249 S. OAK PARK AVE | ||||||||
| Address2: | |||||||||
| City: | BERWYN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087839100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2008 | ||||||||
| LastUpdateDate: | 06/19/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041.326041 | IL | N | Nursing Service Providers | Registered Nurse | 367500000X | 209.007162 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P01211517 | 01 | IL | RAILROAD MEDICARE | OTHER |