Provider Demographics
NPI:1740277441
Name:MORAN, CASEY ANN (PA-C)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:ANN
Last Name:MORAN
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 1:2142 W CHICAGO AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-5203
Mailing Address - Country:US
Mailing Address - Phone:704-616-6508
Mailing Address - Fax:773-834-7137
Practice Address - Street 1:5841 SOUTH MARYLAND AVE
Practice Address - Street 2:UNIVERSITY OF CHICAGO
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637
Practice Address - Country:US
Practice Address - Phone:773-834-7272
Practice Address - Fax:773-834-7137
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000104143363A00000X
IL085003433363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL-35640Medicare UPIN
NC2762054Medicare PIN
NCQ27689Medicare UPIN