Provider Demographics
NPI:1104407451
Name:MOORE, NATHANIEL JAMES ROBERT
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:JAMES ROBERT
Last Name:MOORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15957 FIRTREE DR
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-5834
Mailing Address - Country:US
Mailing Address - Phone:612-558-4112
Mailing Address - Fax:
Practice Address - Street 1:15957 FIRTREE DR
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-5834
Practice Address - Country:US
Practice Address - Phone:612-558-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer