Provider Demographics
NPI:1821492323
Name:MORONG, SHANE MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:MORONG
Suffix:
Gender:M
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 1:100 WILSON RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-7885
Mailing Address - Country:US
Mailing Address - Phone:831-649-1000
Mailing Address - Fax:
Practice Address - Street 1:212 SAN JOSE ST STE 301
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93901-3928
Practice Address - Country:US
Practice Address - Phone:831-759-3289
Practice Address - Fax:831-758-1565
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1551363A00000X
MDC0005588363AS0400X
CA57632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1821492323Medicaid