Provider Demographics
NPI:1962021568
Name:MORENO GONZALEZ, ROBERTO ANTONIO
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:ANTONIO
Last Name:MORENO GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10226 STELLATA LN
Mailing Address - Street 2:
Mailing Address - City:APISON
Mailing Address - State:TN
Mailing Address - Zip Code:37302-1706
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10226 STELLATA LN
Practice Address - Street 2:
Practice Address - City:APISON
Practice Address - State:TN
Practice Address - Zip Code:37302-1706
Practice Address - Country:US
Practice Address - Phone:423-320-1817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor