Basic Information
| Provider Information | |||||||||
| NPI: | 1821607052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOORE | ||||||||
| FirstName: | COLTON | ||||||||
| MiddleName: | RAY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1720 E REELFOOT AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382616049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013500978 | ||||||||
| FaxNumber: | 9013500677 | ||||||||
| Practice Location | |||||||||
| Address1: | 1720 E REELFOOT AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | UNION CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382616049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013500978 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2020 | ||||||||
| LastUpdateDate: | 02/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27851 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.