Provider Demographics
NPI:1114921608
Name:MORAN, ANTOINETTE (PA)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:MORAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3044 ROUTE 50
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-2906
Mailing Address - Country:US
Mailing Address - Phone:518-886-5800
Mailing Address - Fax:518-886-5100
Practice Address - Street 1:3044 ROUTE 50
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-2906
Practice Address - Country:US
Practice Address - Phone:518-886-5800
Practice Address - Fax:518-886-5100
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004432-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CC4279Medicare ID - Type Unspecified
R54904Medicare UPIN