Provider Demographics
NPI:1962004978
Name:MORENO, ANDRES A (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:ANDRES
Middle Name:A
Last Name:MORENO
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 3RD AVE APT 25
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-1857
Mailing Address - Country:US
Mailing Address - Phone:619-410-7215
Mailing Address - Fax:
Practice Address - Street 1:166 3RD AVE APT 25
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-1857
Practice Address - Country:US
Practice Address - Phone:619-410-7215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014745363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care