Basic Information
| Provider Information | |||||||||
| NPI: | 1538680939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | HAYDEN | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6901 SIMMONS LOOP | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335789498 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6901 SIMMONS LOOP | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335789498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8133028000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2017 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 3011467 | KY | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 363LF0000X | 3011467 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 11001495 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 7100540950 | 05 | KY | MEDICAID |