Provider Demographics
NPI:1417724402
Name:FONSECA-MORENO, MIGUEL
Entity Type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:FONSECA-MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 W MARYLAND AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1266
Mailing Address - Country:US
Mailing Address - Phone:480-686-3301
Mailing Address - Fax:
Practice Address - Street 1:80 W MARYLAND AVE APT 207
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-1266
Practice Address - Country:US
Practice Address - Phone:480-686-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant