Provider Demographics
NPI:1184993834
Name:MARONY, GREGORY D (PA)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:D
Last Name:MARONY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-851-7423
Mailing Address - Fax:510-879-9120
Practice Address - Street 1:3630 E IMPERIAL HIGHWAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2636
Practice Address - Country:US
Practice Address - Phone:310-900-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-27
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21884363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner