Provider Demographics
NPI:1275336893
Name:MOORE, JUSTIN THOMAS (APRN)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:THOMAS
Last Name:MOORE
Suffix:
Gender:
Credentials:APRN
Other - Prefix:MR
Other - First Name:JUSTIN
Other - Middle Name:THOMAS
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP
Mailing Address - Street 1:503 E 26TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98421-1343
Mailing Address - Country:US
Mailing Address - Phone:253-881-7001
Mailing Address - Fax:
Practice Address - Street 1:503 E 26TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98421-1343
Practice Address - Country:US
Practice Address - Phone:253-881-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61668130363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty