Provider Demographics
NPI:1568410140
Name:MORAN, VICKY JO (CRNA)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:JO
Last Name:MORAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:VICKY
Other - Middle Name:JO
Other - Last Name:MORAN BAKER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:349 E CORONADO RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1525
Mailing Address - Country:US
Mailing Address - Phone:602-266-5678
Mailing Address - Fax:770-559-1231
Practice Address - Street 1:349 E CORONADO RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1525
Practice Address - Country:US
Practice Address - Phone:602-266-5678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN103578367500000X
AZ251502367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126677Medicaid
LA1143073Medicaid
LA430079025Medicare PIN
LA4C597Medicare PIN
MS00126677Medicaid