Basic Information
| Provider Information | |||||||||
| NPI: | 1255484390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIEDICO | ||||||||
| FirstName: | TANIA | ||||||||
| MiddleName: | MORALES | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022438500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2704 N TENAYA WAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022438500 | ||||||||
| FaxNumber: | 7025602928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2007 | ||||||||
| LastUpdateDate: | 04/02/2014 | ||||||||
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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 | 207Q00000X | ME96208 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000320600 | 05 | FL | MEDICAID | 1255484390 | 05 | NV | MEDICAID | CX4402 | 01 | NV | MEDICARE SMA | OTHER | 92196 | 01 | FL | BCBS | OTHER | 1255484390 | 01 | NV | MEDICAID SMA | OTHER | 13380 | 01 | NV | NV STATE LICENSE | OTHER |