Provider Demographics
NPI:1861409393
Name:MORAN, MAUREEN E (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:E
Last Name:MORAN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:MAUREEN
Other - Middle Name:E
Other - Last Name:HICKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2650 WARRENVILLE RD
Mailing Address - Street 2:STE 280
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515
Mailing Address - Country:US
Mailing Address - Phone:630-324-7911
Mailing Address - Fax:630-324-7942
Practice Address - Street 1:2650 WARRENVILLE RD
Practice Address - Street 2:STE 280
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515
Practice Address - Country:US
Practice Address - Phone:630-324-7911
Practice Address - Fax:630-324-7942
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085000424363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN970002846OtherMEDICAID
IN970002846OtherMEDICAID