Provider Demographics
NPI:1780618249
Name:MORAN, ANTOINETTE MARIE (MD)
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:MARIE
Last Name:MORAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE, MMC 404
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-6777
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE, MMC 404
Practice Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-626-6777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31322208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0051748Medicaid
MN706594700Medicaid
100925OtherUCARE
IA0963157Medicaid
OH0246157OtherOH MA
1009249OtherPREFERRED ONE
WI31504800Medicaid
HP 21999OtherHEALTHPARTNERS
3374526OtherMEDICA PRIMARY
24534OtherARAZ/PPO
MN2T300MOOtherBCBS
3324983OtherMEDICA CHOICE
OH0246157OtherOH MA