Provider Demographics
NPI:1932579620
Name:MORENO, LAUREN CHARLIE (PA)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:CHARLIE
Last Name:MORENO
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-579-3203
Mailing Address - Fax:702-838-1456
Practice Address - Street 1:926 E MCDOWELL RD STE 202
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2508
Practice Address - Country:US
Practice Address - Phone:602-609-4525
Practice Address - Fax:623-584-7194
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2024-02-20
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Provider Licenses
StateLicense IDTaxonomies
AZ6136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ074174Medicaid