MEDICARE: MR. BONNIE MICHELLE MORENO HARRIS PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA14731	CA

General Provider Information

NPI Number	:	1669404380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BONNIE MICHELLE MORENO HARRIS PA

Provider Business Mailing Address
First Line	:	2495 PINE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-3029
Country	:	US
Telephone Number	:	562-477-4244
Fax Number	:	323-726-9789

Provider Business Practice Location Address
First Line	:	2495 PINE AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-3029
Country	:	US
Telephone Number	:	562-477-4244
Fax Number	:	323-726-9789

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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