Provider Demographics
NPI:1235741919
Name:COHEN, MORAN
Entity Type:Individual
Prefix:
First Name:MORAN
Middle Name:
Last Name:COHEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 RIDGE DR E
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-2839
Mailing Address - Country:US
Mailing Address - Phone:516-265-6580
Mailing Address - Fax:
Practice Address - Street 1:30 RIDGE DR E
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-2839
Practice Address - Country:US
Practice Address - Phone:516-265-6580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY026165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program