Healthcare Provider Details

I. General information

NPI: 1821400490
Provider Name (Legal Business Name): JENNIFER MORENO PRIOR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2014
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4455 W 117TH ST #300
HAWTHORNE CA
90250
US

IV. Provider business mailing address

4455 W 117TH ST STE 300
HAWTHORNE CA
90250-2240
US

V. Phone/Fax

Practice location:
  • Phone: 310-645-0444
  • Fax: 310-978-0599
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: