Provider Demographics
NPI:1275824120
Name:MOORE, BRENDA KAY (DO)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
Last Name:MOORE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 OUTLAW RD UNIT 73
Mailing Address - Street 2:
Mailing Address - City:CHURCH ROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87311-0014
Mailing Address - Country:US
Mailing Address - Phone:832-686-1965
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ009519207Q00000X
TXP9912207Q00000X
FLOS12957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine