Healthcare Provider Details

I. General information

NPI: 1669930491
Provider Name (Legal Business Name): CARLOS ALBERTO MORENO JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 BRUNSON DR
CORAL GABLES FL
33146-2412
US

IV. Provider business mailing address

925 NW 97TH AVE APT 206
MIAMI FL
33172-2377
US

V. Phone/Fax

Practice location:
  • Phone: 305-284-3666
  • Fax:
Mailing address:
  • Phone: 786-503-3604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN11006134
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: