Basic Information
Provider Information | |||||||||
NPI: | 1053418921 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOORE | ||||||||
FirstName: | MARTHA | ||||||||
MiddleName: | JANE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOORE | ||||||||
OtherFirstName: | M JANE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1231 | ||||||||
Address2: |   | ||||||||
City: | WRANGELL | ||||||||
State: | AK | ||||||||
PostalCode: | 999291231 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078744700 | ||||||||
FaxNumber: | 9078744719 | ||||||||
Practice Location | |||||||||
Address1: | 232 WOOD STREET | ||||||||
Address2: |   | ||||||||
City: | WRANGELL | ||||||||
State: | AK | ||||||||
PostalCode: | 99929 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9078744700 | ||||||||
FaxNumber: | 9078744719 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 11/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | 6678 | AK | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207Q00000X | 3944 | AK | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | MD8920 | 05 | AK |   | MEDICAID |