Provider Demographics
NPI:1578984712
Name:MORALES, LUPANA REGINA (ATC, LAT)
Entity type:Individual
Prefix:
First Name:LUPANA
Middle Name:REGINA
Last Name:MORALES
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BOX 1129, VC 2210
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62026-0001
Mailing Address - Country:US
Mailing Address - Phone:618-650-2169
Mailing Address - Fax:
Practice Address - Street 1:35 CIRCLE DR
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62026-2210
Practice Address - Country:US
Practice Address - Phone:618-650-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-13
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0056022081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine