Provider Demographics
NPI:1144275215
Name:MOORE, SHELLEY W (MD)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:W
Last Name:MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 RIVERSIDE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-4353
Mailing Address - Country:US
Mailing Address - Phone:970-224-1670
Mailing Address - Fax:970-495-6218
Practice Address - Street 1:3519 RICHMOND DR
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80526-5995
Practice Address - Country:US
Practice Address - Phone:970-204-0300
Practice Address - Fax:970-221-5206
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO54549207P00000X
TXM1248207P00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175660301Medicaid
TX175660302Medicaid
TX175660302Medicaid
TX8D6585Medicare ID - Type Unspecified
TX175660302Medicaid