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General NPI Number Information
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NPI Number | 1801074224
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Entity Type | Individual
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Provider Name | JOHN W MORENO RPA-C
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Gender | Male
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Dates
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Enumeration Date | 02/07/2008
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Last Update Date | 02/07/2008
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Provider Practice Location Address
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Address Line | 2915 SUNRISE HWY
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City | ISLIP TERRACE
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State | NY
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Zip | 11752-2716
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Country | US
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Telephone | 631-665-8006
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Fax |
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Provider Business Mailing Address
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Address Line | 206 MARTHA AVE
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City | EAST PATCHOGUE
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State | NY
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Zip | 11772-4948
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Country | US
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Telephone | 631-375-1577
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 012343
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License Number State | NY
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