Basic Information
| Provider Information | |||||||||
| NPI: | 1346575081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | STE 310 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 8669392673 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 N LITCHFIELD RD STE 110 | ||||||||
| Address2: | |||||||||
| City: | GOODYEAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853381226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022562525 | ||||||||
| FaxNumber: | 6022560795 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2009 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 58.003264 | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207XS0114X | 006433 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 174400000X | 006433 | AZ | N | Other Service Providers | Specialist | 207X00000X | 006433 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208600000X | 006433 | AZ | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 916205 | 05 | AZ | MEDICAID |