Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | IN01038003A | IN |
Y | 208600000X | Surgeon | IN01038003A | IN |
NPI | 1003824004 |
---|---|
Provider Name | Wayne E Moore |
First Address | Laporte, IN 46352-1690 |
Second Address | Laporte, IN 46350 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/08/2006 |
Last Update Date | 12/11/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
01038003 | LICENSE NUMBER (01) | |
01038003B | CSR (01) | IN |
100367770A | (05) | IN |
BM2144474 | DEA (01) | IN |
E33590 | (02) |