Provider Demographics
NPI:1659598795
Name:MORON, MARY TRICHE (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:TRICHE
Last Name:MORON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:806 JEFFERSON TER
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-5727
Mailing Address - Country:US
Mailing Address - Phone:337-367-3992
Mailing Address - Fax:337-367-3994
Practice Address - Street 1:1002 12TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-6224
Practice Address - Country:US
Practice Address - Phone:337-534-0107
Practice Address - Fax:337-534-0184
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP03778363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1140082Medicaid