Healthcare Provider Details

I. General information

NPI: 1265743397
Provider Name (Legal Business Name): LAURA ELIZABETH MORENO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 TALBOT RD S STE 401
RENTON WA
98055-5738
US

IV. Provider business mailing address

PO BOX 34876
SEATTLE WA
98124-1876
US

V. Phone/Fax

Practice location:
  • Phone: 425-656-4224
  • Fax: 425-656-5099
Mailing address:
  • Phone: 425-656-5412
  • Fax: 425-656-4096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125057636
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number1362895-1205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60382871
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: