Provider Demographics
NPI:1336226109
Name:MOORE, ROBERT (CRNA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:MOORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 WEST WALNUT AVENUE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220
Mailing Address - Country:US
Mailing Address - Phone:318-323-0838
Mailing Address - Fax:
Practice Address - Street 1:323 WEST WALNUT AVENUE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220
Practice Address - Country:US
Practice Address - Phone:318-323-0838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA094741207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4C666CY90Medicare PIN
LA4C666CF16Medicare ID - Type Unspecified