Healthcare Provider Details

I. General information

NPI: 1255484390
Provider Name (Legal Business Name): TANIA MORALES MIEDICO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 04/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 N TENAYA WAY SUITE 200
LAS VEGAS NV
89128-0424
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-243-8500
  • Fax: 702-560-2928
Mailing address:
  • Phone: 702-243-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME96208
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: