Provider Demographics
NPI:1700252822
Name:MOREDOCK, SASHA L (APN)
Entity Type:Individual
Prefix:MISS
First Name:SASHA
Middle Name:L
Last Name:MOREDOCK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5111 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4675
Mailing Address - Country:US
Mailing Address - Phone:309-683-5700
Mailing Address - Fax:309-683-5752
Practice Address - Street 1:287 PARK AVE S FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-4573
Practice Address - Country:US
Practice Address - Phone:888-553-2823
Practice Address - Fax:857-305-0177
Is Sole Proprietor?:No
Enumeration Date:2015-08-12
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013058363LF0000X
NY350128363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner