Provider Demographics
NPI:1831105287
Name:JACK-MOONEY, NOREEN TRESA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:NOREEN
Middle Name:TRESA
Last Name:JACK-MOONEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NOREEN
Other - Middle Name:TRESA
Other - Last Name:JACK-MOONEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:
Practice Address - Street 1:80 B VETERANS BLVD
Practice Address - Street 2:I-40, EXIT 102
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5300
Practice Address - Fax:505-552-5828
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD-276363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH3451Medicaid
NMH3451Medicaid