Provider Demographics
NPI:1003381583
Name:MORENO, EDGAR (PA-C)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 CADMUS CT
Mailing Address - Street 2:
Mailing Address - City:ARVIN
Mailing Address - State:CA
Mailing Address - Zip Code:93203-2000
Mailing Address - Country:US
Mailing Address - Phone:661-557-0847
Mailing Address - Fax:
Practice Address - Street 1:6001 TRUXTUN AVE
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93309-0679
Practice Address - Country:US
Practice Address - Phone:661-323-8477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA57434207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program