Provider Demographics
NPI:1295713881
Name:POREMBA, MARY JO (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JO
Last Name:POREMBA
Suffix:
Gender:F
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 1:520 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6194
Mailing Address - Country:US
Mailing Address - Phone:309-762-3621
Mailing Address - Fax:309-762-3690
Practice Address - Street 1:520 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6152
Practice Address - Country:US
Practice Address - Phone:309-762-3621
Practice Address - Fax:309-762-3690
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001152363A00000X
IA001636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
97854OtherWELLMARK
234526OtherMIDLANDS CHOICE
193318OtherIA HEALTH SOLUTIONS
970021096OtherRR MEDICARE
IL0168OtherJOHN DEERE FAMILY
IL8121085OtherBCBS
IL0168OtherJOHN DEERE FAMILY
193318OtherIA HEALTH SOLUTIONS