MEDICARE: NATALIA GABRIELA MOCTEZUMA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL5329	FL
2	225100000X	Physical Therapist	PT39102	FL

General Provider Information

NPI Number	:	1194227264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NATALIA GABRIELA MOCTEZUMA

Provider Business Mailing Address
First Line	:	13670 HIDDEN FOREST CIR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32828-6815
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13801 WALSINGHAM RD STE G
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33774-3237
Country	:	US
Telephone Number	:	727-593-7909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2018
Last Update Date	:	08/05/2022

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