Provider Demographics
NPI:1033531181
Name:MOORE, TINA (NP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6398 SE RHODUS LN
Mailing Address - Street 2:
Mailing Address - City:LAWSON
Mailing Address - State:MO
Mailing Address - Zip Code:64062-7212
Mailing Address - Country:US
Mailing Address - Phone:816-918-8201
Mailing Address - Fax:
Practice Address - Street 1:1860 N CHURCH RD
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068
Practice Address - Country:US
Practice Address - Phone:816-415-2828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-08
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014000703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2014000703OtherLICENSE
MO1033531181Medicaid