Provider Demographics
NPI:1861564387
Name:MOORE, SHERI A (LSA)
Entity type:Individual
Prefix:
First Name:SHERI
Middle Name:A
Last Name:MOORE
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:SHERI
Other - Middle Name:JEAN
Other - Last Name:SMITH / ADAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 40307
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704
Mailing Address - Country:US
Mailing Address - Phone:806-787-7840
Mailing Address - Fax:806-794-0125
Practice Address - Street 1:910 BUNTON LN
Practice Address - Street 2:
Practice Address - City:UHLAND
Practice Address - State:TX
Practice Address - Zip Code:78640-6404
Practice Address - Country:US
Practice Address - Phone:806-787-7840
Practice Address - Fax:806-794-0125
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA0047174400000X, 363AS0400X
TXSA00047208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0062JROtherBLUE CROSS & BLUE SHIELD
TX208600000XOtherTAXONOMY