Provider Demographics
NPI:1487384459
Name:MORAN, JONATHAN OSCAR
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:OSCAR
Last Name:MORAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10541 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-1538
Mailing Address - Country:US
Mailing Address - Phone:818-951-6111
Mailing Address - Fax:
Practice Address - Street 1:10541 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042-1538
Practice Address - Country:US
Practice Address - Phone:818-951-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
CA61787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant