Basic Information
| Provider Information | |||||||||
| NPI: | 1275991929 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 232410 | ||||||||
| Address2: | 200-B | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921932410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582496749 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1855 1ST AVE | ||||||||
| Address2: | 200-B | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921012685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192334044 | ||||||||
| FaxNumber: | 6192334144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2016 | ||||||||
| LastUpdateDate: | 12/09/2016 | ||||||||
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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 | 363LA2200X | 695565 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.