Healthcare Provider Details

I. General information

NPI: 1679128490
Provider Name (Legal Business Name): JONATHAN MORENO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16890 FOREST RD
FOREST VA
24551-4059
US

IV. Provider business mailing address

16890 FOREST RD
FOREST VA
24551-4059
US

V. Phone/Fax

Practice location:
  • Phone: 434-200-7210
  • Fax:
Mailing address:
  • Phone: 434-200-7210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006885
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: