Provider Demographics
NPI:1548359946
Name:MORENO, MARY DONOVAN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:DONOVAN
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 S 24TH ST
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-4919
Mailing Address - Country:US
Mailing Address - Phone:307-755-9737
Mailing Address - Fax:307-721-1039
Practice Address - Street 1:1465 N 4TH ST
Practice Address - Street 2:SUITE 119
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82072-2066
Practice Address - Country:US
Practice Address - Phone:307-721-0700
Practice Address - Fax:307-721-1039
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6594A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYF97995Medicare UPIN
WY61169615FMedicare ID - Type Unspecified