Basic Information
| Provider Information | |||||||||
| NPI: | 1295713881 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POREMBA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JO | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 VALLEY VIEW DR | ||||||||
| Address2: | |||||||||
| City: | MOLINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 612656152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3097623621 | ||||||||
| FaxNumber: | 3097623690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 01/06/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085001152 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 001636 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 97854 | 01 | WELLMARK | OTHER | 234526 | 01 | MIDLANDS CHOICE | OTHER | 193318 | 01 | IA HEALTH SOLUTIONS | OTHER | 970021096 | 01 | RR MEDICARE | OTHER | IL0168 | 01 | JOHN DEERE FAMILY | OTHER | 8121085 | 01 | IL | BCBS | OTHER |