Healthcare Provider Details

I. General information

NPI: 1093321085
Provider Name (Legal Business Name): LARRY ANTHONY MORALES FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 N MAIN ST STE 1A
SAN LUIS AZ
85336-0663
US

IV. Provider business mailing address

PO BOX 617
SOMERTON AZ
85350-0617
US

V. Phone/Fax

Practice location:
  • Phone: 928-550-5514
  • Fax: 928-550-5160
Mailing address:
  • Phone: 928-315-7910
  • Fax: 928-722-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number247394
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: