Provider Demographics
NPI:1619608858
Name:LIRIANO-FERNANDEZ, MOISES (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:MOISES
Middle Name:
Last Name:LIRIANO-FERNANDEZ
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 BROAD ST STE 606
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-4537
Mailing Address - Country:US
Mailing Address - Phone:201-822-1161
Mailing Address - Fax:877-485-8918
Practice Address - Street 1:550 BROAD ST STE 606
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4537
Practice Address - Country:US
Practice Address - Phone:201-822-1161
Practice Address - Fax:877-485-8918
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01319200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0921939Medicaid