Active NPI
Jackson T Moran
- Student in an Organized Health Care Education/Training Program
- Minneapolis, MN
National Provider Identifier
1104574680
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Student in an Organized Health Care Education/Training Program
- Practice address
- 701 Park Ave
Minneapolis, MN 55415-1623 - Phone
- (612) 873-3000
- NPI assigned
- Mar 14, 2022
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | Primary |
Addresses
Primary practice location
701 Park Ave
Minneapolis, MN 55415-1623
Mailing address
701 Park Ave
Minneapolis, MN 55415-1623
Phone (612) 873-3000
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20260610000830 | MN | Practitioner - Emergency Medicine | 2264890904 |
Care Compare profile
Medicare Care Compare- Specialty
- Emergency Medicine
- Education
- University of Chicago, Pritzker School of Medicine, 2023
- Medicare assignment
- May accept Medicare assignment
Practice addresses (Care Compare)
500 S Maple St
Waconia, MN 55387-1791
500 S Maplt St
Attn Medical Staff Office
Waconia, MN 55387-1791
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 33671 | MN | MD | Family Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1647216000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1680825600000",
"number": "1104574680",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "701 PARK AVE",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554151623",
"telephone_number": "612-873-3000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "701 PARK AVE",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554151623",
"telephone_number": "612-873-3000"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MORAN",
"first_name": "JACKSON",
"middle_name": "T",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2022-03-14",
"last_updated": "2023-04-07",
"certification_date": "2023-04-07",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Minneapolis, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 7, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.