Provider Demographics
NPI:1114292786
Name:MORENO-CABRERA, PATRICIA
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:MORENO-CABRERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:BILLING DEPT - CREDENTIALIST
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-286-4560
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:6255 QUEBEC PKWY
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-4812
Practice Address - Country:US
Practice Address - Phone:303-286-6755
Practice Address - Fax:303-286-4970
Is Sole Proprietor?:No
Enumeration Date:2012-03-15
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMDD3845122300000X
CODEN.00202526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87780054Medicaid
CO840613540Medicare PIN