Provider Demographics
NPI:1275991929
Name:MORENO, MANUEL A (NP)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:A
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:PO BOX 232410
Mailing Address - Street 2:200-B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:858-249-6749
Mailing Address - Fax:
Practice Address - Street 1:1855 1ST AVE
Practice Address - Street 2:200-B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2685
Practice Address - Country:US
Practice Address - Phone:619-233-4044
Practice Address - Fax:619-233-4144
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA695565363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health