Healthcare Provider Details

I. General information

NPI: 1861863243
Provider Name (Legal Business Name): LEROY MORENO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1506 LONESTAR PLAZA WAY STE 7
EDINBURG TX
78539-0228
US

IV. Provider business mailing address

2046 S MCCOLL RD
EDINBURG TX
78539-0228
US

V. Phone/Fax

Practice location:
  • Phone: 956-348-2918
  • Fax: 956-348-2927
Mailing address:
  • Phone: 956-393-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberH8062
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: