Provider Demographics
NPI:1548610710
Name:MORAN, DONALD JON (AT,ATC)
Entity Type:Individual
Prefix:MR
First Name:DONALD
Middle Name:JON
Last Name:MORAN
Suffix:
Gender:M
Credentials:AT,ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 NIGHTINGALE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1007
Mailing Address - Country:US
Mailing Address - Phone:313-400-0213
Mailing Address - Fax:
Practice Address - Street 1:1330 NIGHTINGALE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48128-1007
Practice Address - Country:US
Practice Address - Phone:313-400-0213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003153-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer