Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 10451 | TX |
NPI | 1396823084 |
---|---|
Provider Name | Dr. Jason Nicholas Moore |
First Address | Lewisville, TX 75077-7691 |
Second Address | Colleyville, TX 76034-7914 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/11/2006 |
Last Update Date | 17/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8AP440 | BLUE CROSS BLUE SHEILDS (01) | TX |