Healthcare Provider Details

I. General information

NPI: 1164170106
Provider Name (Legal Business Name): AMAURY FABIAN FELICIANO MORA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 04/26/2023
Certification Date: 04/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ESTANCIAS DE MANATI 10 CALLE CALAMAR
MANATI PR
00674
US

IV. Provider business mailing address

ESTANCIAS DE MANATI 10 CALLE CALAMAR
MANATI PR
00674
US

V. Phone/Fax

Practice location:
  • Phone: 787-900-2765
  • Fax:
Mailing address:
  • Phone: 787-900-2765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1045-PA
License Number StatePR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: