Provider Demographics
NPI:1013426683
Name:MORENO, MICHELLE ELISE (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELISE
Last Name:MORENO
Suffix:
Gender:F
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 1:3934 28TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101-3729
Mailing Address - Country:US
Mailing Address - Phone:631-235-6098
Mailing Address - Fax:
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1850
Practice Address - Country:US
Practice Address - Phone:212-434-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical