Provider Demographics
NPI:1427247121
Name:MOORE, MICHAEL JUSTIN (ARNP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JUSTIN
Last Name:MOORE
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2610 N WOODLAWN BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67220-2729
Mailing Address - Country:US
Mailing Address - Phone:316-858-2885
Mailing Address - Fax:316-858-2530
Practice Address - Street 1:2610 N WOODLAWN BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67220-2729
Practice Address - Country:US
Practice Address - Phone:316-858-2885
Practice Address - Fax:316-858-2530
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS46060363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200536250CMedicaid
KSP00630601OtherRR MEDICARE
KS004052007Medicare UPIN
KSKA1092015Medicare PIN