Healthcare Provider Details

I. General information

NPI: 1295713881
Provider Name (Legal Business Name): MARY JO POREMBA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 VALLEY VIEW DR
MOLINE IL
61265-6152
US

IV. Provider business mailing address

520 VALLEY VIEW DR
MOLINE IL
61265-6194
US

V. Phone/Fax

Practice location:
  • Phone: 309-762-3621
  • Fax: 309-762-3690
Mailing address:
  • Phone: 309-762-3621
  • Fax: 309-762-3690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085001152
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001636
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: