Provider Demographics
NPI:1992258131
Name:MOORE, SHANTRAE
Entity type:Individual
Prefix:
First Name:SHANTRAE
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 S FRAZIER ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77301-4453
Mailing Address - Country:US
Mailing Address - Phone:936-441-2440
Mailing Address - Fax:
Practice Address - Street 1:1414 S FRAZIER ST STE 105
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77301-4475
Practice Address - Country:US
Practice Address - Phone:936-441-2440
Practice Address - Fax:800-249-5020
Is Sole Proprietor?:No
Enumeration Date:2016-07-24
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX757931363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily