Provider Demographics
NPI:1366844987
Name:MORENO, ROBIN (RN, ACAGNP)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:RN, ACAGNP
Other - Prefix:MRS
Other - First Name:ROBIN
Other - Middle Name:
Other - Last Name:GANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 50268
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76206-0268
Mailing Address - Country:US
Mailing Address - Phone:940-484-1500
Mailing Address - Fax:940-484-1700
Practice Address - Street 1:221 W COLORADO BLVD STE 525
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2312
Practice Address - Country:US
Practice Address - Phone:214-960-5681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2019-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126489363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX344003YZYHMedicare PIN
TX344003ZT4KMedicare PIN