Provider Demographics
NPI:1154747368
Name:MORAN, CHASE
Entity type:Individual
Prefix:
First Name:CHASE
Middle Name:
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 1:2104 GROVEGLEN LN S
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-3719
Mailing Address - Country:US
Mailing Address - Phone:863-944-5264
Mailing Address - Fax:
Practice Address - Street 1:2104 GROVEGLEN LN S
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-3719
Practice Address - Country:US
Practice Address - Phone:863-944-5264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23272225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant