Basic Information
| Provider Information | |||||||||
| NPI: | 1972550184 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARONEY | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12127B HWY 14N SUITE 5 | ||||||||
| Address2: | |||||||||
| City: | CEDAR CREST | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870089499 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052815180 | ||||||||
| FaxNumber: | 5052815320 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 W US ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | MORIARTY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870351006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058324434 | ||||||||
| FaxNumber: | 5058325024 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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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 | 363AM0700X | PA2003-0005 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.