Healthcare Provider Details

I. General information

NPI: 1568178762
Provider Name (Legal Business Name): PATRICK JAMES MORAN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2023
Last Update Date: 01/31/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4199
US

IV. Provider business mailing address

1590 KEVIN LN
DELAND FL
32724-7920
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: