Basic Information
| Provider Information | |||||||||
| NPI: | 1467617407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | SUSAN | ||||||||
| MiddleName: | JOANA | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 KUENZLI ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895020837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759824590 | ||||||||
| FaxNumber: | 7759825496 | ||||||||
| Practice Location | |||||||||
| Address1: | 975 RYLAND ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895021669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7759825000 | ||||||||
| FaxNumber: | 7759825225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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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 | APRN001004 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1467617407 | 05 | NV | MEDICAID | 12215917 | 01 | CAQH | OTHER |