Basic Information
| Provider Information | |||||||||
| NPI: | 1619077476 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORAN | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 140349 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995140349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072747977 | ||||||||
| FaxNumber: | 9072747986 | ||||||||
| Practice Location | |||||||||
| Address1: | 2751 DEBARR RD | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995082953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072747977 | ||||||||
| FaxNumber: | 9072747986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 5136 | AK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | MD2611 | 05 | AK | MEDICAID | P00058744 | 01 | RAIL ROAD MEDICARE | OTHER |