Basic Information
| Provider Information | |||||||||
| NPI: | 1174780811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOYER | ||||||||
| FirstName: | KURTIS | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 RIVERSIDE CIR | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240164955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245170 | ||||||||
| FaxNumber: | 5409823434 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 RIVERSIDE CIR | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240164955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245170 | ||||||||
| FaxNumber: | 5409823434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2008 | ||||||||
| LastUpdateDate: | 05/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 128607 | NC | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208600000X | 0101-253023 | VA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0122X | 0101-253023 | VA | Y | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | VV8610A | 01 | VA | MEDICARE PTAN | OTHER |