Healthcare Provider Details

I. General information

NPI: 1831166800
Provider Name (Legal Business Name): LISA M. MORENO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 FRESNO ST
FRESNO CA
93721-1324
US

IV. Provider business mailing address

2625 E DIVISADERO ST
FRESNO CA
93721-1431
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-6000
  • Fax: 559-459-3750
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA18308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: