Provider Demographics
NPI:1275600843
Name:MORAN, TAMMY JO (PA)
Entity Type:Individual
Prefix:MRS
First Name:TAMMY
Middle Name:JO
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 1:1300 W 2ND ST.
Mailing Address - Street 2:
Mailing Address - City:ROCK FALLS
Mailing Address - State:IL
Mailing Address - Zip Code:61071-1005
Mailing Address - Country:US
Mailing Address - Phone:815-626-2230
Mailing Address - Fax:815-626-3729
Practice Address - Street 1:1300 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROCK FALLS
Practice Address - State:IL
Practice Address - Zip Code:61071-1005
Practice Address - Country:US
Practice Address - Phone:815-626-2230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001786363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-001786OtherILLINOIS LICENSE NUMBER
IL1528008034OtherORGANIZATION NPI NUMBER
IL1035875OtherPA CERTIFICATION NUMBER