Basic Information
| Provider Information | |||||||||
| NPI: | 1063490290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | MILAN | ||||||||
| MiddleName: | SHANNON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 368 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985070368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604918439 | ||||||||
| FaxNumber: | 3604916328 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 CAPITAL MALL DR SW STE A | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985028654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607868990 | ||||||||
| FaxNumber: | 3607869010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207X00000X | MD00039784 | WA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 148355 | 01 | WA | LABOR & INDUSTRIES | OTHER | 5918MO | 01 | WA | REGENCE | OTHER | GAB21356 | 01 | WA | MEDICARE LEGACY | OTHER | 1001556 | 05 | WA | MEDICAID | 8275349 | 01 | WA | DSHS | OTHER |