Healthcare Provider Details

I. General information

NPI: 1871059196
Provider Name (Legal Business Name): MICHAELA MORAN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 JOHN PROM BLVD
JACKSONVILLE FL
32246-3921
US

IV. Provider business mailing address

14 FISHER RD
EAST FALMOUTH MA
02536-7145
US

V. Phone/Fax

Practice location:
  • Phone: 774-392-5429
  • Fax:
Mailing address:
  • Phone: 774-392-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAL5424
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: