Provider Demographics
NPI:1760041917
Name:MORAN, JILLIAN MARY (PA)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:MARY
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 1:170 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-2612
Mailing Address - Country:US
Mailing Address - Phone:646-707-5996
Mailing Address - Fax:
Practice Address - Street 1:170 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2612
Practice Address - Country:US
Practice Address - Phone:212-312-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant