Provider Demographics
NPI:1164977005
Name:MUNENO, ANDO (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDO
Middle Name:
Last Name:MUNENO
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 1:220 NEWPORT CENTER DR # 11-282
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7506
Mailing Address - Country:US
Mailing Address - Phone:310-971-3243
Mailing Address - Fax:
Practice Address - Street 1:3501 JAMBOREE RD STE 1250
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2939
Practice Address - Country:US
Practice Address - Phone:310-971-3243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-21
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-005499363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant