Basic Information
| Provider Information | |||||||||
| NPI: | 1710971908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORAN | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22407 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631260407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363867222 | ||||||||
| FaxNumber: | 6363867810 | ||||||||
| Practice Location | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6363867222 | ||||||||
| FaxNumber: | 6363867810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2005 | ||||||||
| LastUpdateDate: | 02/12/2016 | ||||||||
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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 | 367500000X | C01016 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | APN0000010072 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 128948 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 143653701 | 05 | AR | MEDICAID | 4068895 | 01 | TN | BLUE CROSS TN PROV # | OTHER | 3629651 | 05 | TN | MEDICAID | 911331007 | 05 | MO | MEDICAID | 900418777 | 01 | MO | RR MEDICARE | OTHER | 5T743 | 01 | AR | BLUE CROSS AR PROV # | OTHER |