Provider Demographics
NPI:1255355707
Name:MORAN, MICHELLE P (PHD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:P
Last Name:MORAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:MICHELLE
Other - Middle Name:P
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:219 E LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-3955
Mailing Address - Country:US
Mailing Address - Phone:210-333-4755
Mailing Address - Fax:210-333-1833
Practice Address - Street 1:219 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3955
Practice Address - Country:US
Practice Address - Phone:210-333-4755
Practice Address - Fax:210-333-1833
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23265170100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170100000XOther Service ProvidersMedical Genetics, Ph.D. Medical Genetics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032702501Medicaid
TX17429865896000Medicare UPIN
TX8B1303Medicare ID - Type Unspecified