Provider Demographics
NPI:1831764844
Name:MOOMAW, REGAN (DPT)
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:
Last Name:MOOMAW
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:REGAN
Other - Middle Name:
Other - Last Name:MANSUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:511 S HAMILTON ST
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-2103
Mailing Address - Country:US
Mailing Address - Phone:217-358-1456
Mailing Address - Fax:
Practice Address - Street 1:2611 S BANKER ST
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2980
Practice Address - Country:US
Practice Address - Phone:217-358-1456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-21
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic