Provider Demographics
NPI:1851717912
Name:MORENO, RAYMOND (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PEAKWOOD DR STE 5D
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2903
Mailing Address - Country:US
Mailing Address - Phone:713-447-3226
Mailing Address - Fax:
Practice Address - Street 1:800 PEAKWOOD DR STE 5D
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2903
Practice Address - Country:US
Practice Address - Phone:713-447-3226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125390363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX353088301Medicaid
TX353088301Medicaid