Healthcare Provider Details

I. General information

NPI: 1912216995
Provider Name (Legal Business Name): SAMUEL FELICIANO MORALES PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2010
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 MERCED ST
FRESNO CA
93721-1811
US

IV. Provider business mailing address

1350 O ST STE 302
FRESNO CA
93721-1828
US

V. Phone/Fax

Practice location:
  • Phone: 559-445-0391
  • Fax:
Mailing address:
  • Phone: 559-369-4625
  • Fax: 559-369-7259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA21200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: