Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 101511 | AK |
N | 208000000X | Pediatrician | 101511 | AK |
NPI | 1710977822 |
---|---|
Provider Name | Mrs. Laura M Moore |
First Address | Anchorage, AK 99508 |
Second Address | Anchorage, AK 99508 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/10/2005 |
Last Update Date | 16/11/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
12268 | LICENSE (01) | MT |