Provider Demographics
NPI:1407349715
Name:MORENO, IKAIKA K (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:IKAIKA
Middle Name:K
Last Name:MORENO
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 S CIMARRON RD STE 155
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2170
Mailing Address - Country:US
Mailing Address - Phone:725-252-8089
Mailing Address - Fax:
Practice Address - Street 1:7220 S CIMARRON RD STE 155
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113-2170
Practice Address - Country:US
Practice Address - Phone:725-252-8089
Practice Address - Fax:800-532-0674
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN80851163WE0003X
HIAPRN-2456363LF0000X
NV812685363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV812685OtherSTATE LICENSE
NV1407349715Medicaid