Provider Demographics
NPI:1235175332
Name:MORENO, AMY K (MD)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:K
Last Name:MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8525 ROLLING RD STE 220
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-3648
Mailing Address - Country:US
Mailing Address - Phone:703-393-0700
Mailing Address - Fax:703-393-0661
Practice Address - Street 1:8525 ROLLING RD
Practice Address - Street 2:SUITE 220
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-3647
Practice Address - Country:US
Practice Address - Phone:703-393-0700
Practice Address - Fax:703-393-0661
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2019-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101226910207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H54863Medicare UPIN
00776P76Medicare ID - Type Unspecified