Healthcare Provider Details

I. General information

NPI: 1114030681
Provider Name (Legal Business Name): MELISSA L MORENO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 W 15TH ST
AUSTIN TX
78701-1511
US

IV. Provider business mailing address

8426 SPRINGFIELD GORGE DR
AUSTIN TX
78681-3543
US

V. Phone/Fax

Practice location:
  • Phone: 254-258-4649
  • Fax: 315-772-9498
Mailing address:
  • Phone: 512-582-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: