Provider Demographics
NPI:1295787448
Name:MORONG, DOUGLAS M (PA-C)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
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 1:376 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKMAN
Mailing Address - State:ME
Mailing Address - Zip Code:04945-5214
Mailing Address - Country:US
Mailing Address - Phone:207-668-2691
Mailing Address - Fax:207-668-7605
Practice Address - Street 1:376 MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKMAN
Practice Address - State:ME
Practice Address - Zip Code:04945-5214
Practice Address - Country:US
Practice Address - Phone:207-668-2691
Practice Address - Fax:207-668-7605
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES30581Medicare UPIN
MEAP0580Medicare PIN
MEME 0304Medicare ID - Type Unspecified
MEP00318041Medicare PIN