Provider Demographics
NPI:1508167172
Name:MARONG, JEANNINE LOUISE (PA-C)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:LOUISE
Last Name:MARONG
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5455 N MARGINAL RD
Mailing Address - Street 2:APARTMENT #328
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44114-3937
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-0261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003188363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical