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General NPI Number Information
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NPI Number | 1639469224
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Entity Type | Individual
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Provider Name | JONATHAN MORAN PT
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Gender | Male
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Dates
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Enumeration Date | 04/15/2011
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Last Update Date | 04/15/2011
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Provider Practice Location Address
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Address Line | 711 AVIGNON DR
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City | RIDGELAND
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State | MS
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Zip | 39157-5120
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Country | US
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Telephone | 601-605-6777
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Fax |
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Provider Business Mailing Address
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Address Line | 15093 DOBSON RD
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City | BILOXI
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State | MS
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Zip | 39532-9130
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Country | US
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Telephone | 228-218-7468
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | PT4488
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License Number State | MS
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