Provider Demographics
NPI:1497202071
Name:MORENO, YONNY LUIS (SA-C)
Entity Type:Individual
Prefix:
First Name:YONNY
Middle Name:LUIS
Last Name:MORENO
Suffix:
Gender:M
Credentials:SA-C
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 3025
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77253-3025
Mailing Address - Country:US
Mailing Address - Phone:713-271-2384
Mailing Address - Fax:713-583-2061
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:1610
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-271-2384
Practice Address - Fax:713-583-2061
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14-498363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical