Provider Demographics
NPI:1003381583
Name:MORENO, EDGAR (PA-C)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1139
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1139
Mailing Address - Country:US
Mailing Address - Phone:661-371-2796
Mailing Address - Fax:661-438-1746
Practice Address - Street 1:3008 SILLECT AVE STE 220
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-6362
Practice Address - Country:US
Practice Address - Phone:661-748-1999
Practice Address - Fax:661-748-1815
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57434363A00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant