Basic Information
| Provider Information | |||||||||
| NPI: | 1619953734 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MOORE | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 912215 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802912215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1024 S LEMAY AVE | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805243929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2005 | ||||||||
| LastUpdateDate: | 03/07/2014 | ||||||||
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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 | 363L00000X | NP-3071 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | NP-3071 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | RN-6552 | CO | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 00833843 | 05 | CO | MEDICAID | P01148022 | 01 | CO | RAILROAD MEDICARE PIN | OTHER | P00944802 | 01 | CO | MEDICARE RAILROAD CARRIER PTAN | OTHER |