Basic Information
| Provider Information | |||||||||
| NPI: | 1750342721 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORENO | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1229 C AVE E | ||||||||
| Address2: | |||||||||
| City: | OSKALOOSA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525774246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416723100 | ||||||||
| FaxNumber: | 6416723111 | ||||||||
| Practice Location | |||||||||
| Address1: | 1229 C AVE E | ||||||||
| Address2: | |||||||||
| City: | OSKALOOSA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 525774246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416723100 | ||||||||
| FaxNumber: | 6416723111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 01/23/2014 | ||||||||
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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 | 03686 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.