Provider Demographics
NPI:1093251233
Name:MORENO, CARLOS ADOLFO (NP)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:ADOLFO
Last Name:MORENO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 S WESTLAKE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90057-3525
Mailing Address - Country:US
Mailing Address - Phone:213-674-7769
Mailing Address - Fax:
Practice Address - Street 1:635 S WESTLAKE AVE STE 101
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3525
Practice Address - Country:US
Practice Address - Phone:213-674-7769
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2023-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005615363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner