Provider Demographics
NPI:1689353427
Name:MOORE, SHANE M (MPSS-DSNBAR)
Entity type:Individual
Prefix:MR
First Name:SHANE
Middle Name:M
Last Name:MOORE
Suffix:
Gender:M
Credentials:MPSS-DSNBAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12183 LOCKSLEY LN STE 101
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95602-2050
Mailing Address - Country:US
Mailing Address - Phone:530-885-1961
Mailing Address - Fax:
Practice Address - Street 1:12183 LOCKSLEY LN STE 101
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95602-2050
Practice Address - Country:US
Practice Address - Phone:530-885-1961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSS-DANBAR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker