Provider Demographics
NPI:1871059196
Name:MORAN, MICHAELA (ATC)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:MORAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 FISHER RD
Mailing Address - Street 2:
Mailing Address - City:EAST FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02536-7145
Mailing Address - Country:US
Mailing Address - Phone:774-392-5429
Mailing Address - Fax:
Practice Address - Street 1:2750 JOHN PROM BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-3921
Practice Address - Country:US
Practice Address - Phone:774-392-5429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL54242081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine