Provider Demographics
NPI:1174830210
Name:MORAN MARTINEZ, CARLOS A
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:A
Last Name:MORAN MARTINEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:305-271-9777
Mailing Address - Fax:
Practice Address - Street 1:15955 SW 96TH ST STE 102
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33196-1272
Practice Address - Country:US
Practice Address - Phone:305-271-9777
Practice Address - Fax:786-533-9383
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002480363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner