Provider Demographics
NPI:1417183450
Name:MORENO, MODESTO A (PA-C)
Entity Type:Individual
Prefix:
First Name:MODESTO
Middle Name:A
Last Name:MORENO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26659 PLEASANT PARK RD
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-7714
Mailing Address - Country:US
Mailing Address - Phone:303-674-0605
Mailing Address - Fax:303-674-9496
Practice Address - Street 1:26659 PLEASANT PARK RD
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433-7714
Practice Address - Country:US
Practice Address - Phone:303-674-0605
Practice Address - Fax:303-674-9496
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO451363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical