Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0103X | Foot & Ankle Surgery | 1051 | MN |
N | 213ES0103X | Foot & Ankle Surgery | PO3825 | FL |
NPI | 1093155442 |
---|---|
Provider Name | Dr. Kyle R Moore |
First Address | Crosby, MN 56441 |
Second Address | Crosby, MN 56441 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2013 |
Last Update Date | 19/11/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BJ7BU | FLORIDA BLUE (01) | FL |