MEDICARE: LISA MORENO APRN

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	363LA2200X	Adult Health Nurse Practitioner	APRN002443	NV

General Provider Information

NPI Number	:	1194262519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MORENO APRN

Provider Business Mailing Address
First Line	:	4357 CORPORATE CENTER DR STE 450
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-0226
Country	:	US
Telephone Number	:	702-644-4673
Fax Number	:	702-902-4453

Provider Business Practice Location Address
First Line	:	4357 CORPORATE CENTER DR STE 450
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-0226
Country	:	US
Telephone Number	:	702-644-4673
Fax Number	:

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

Provider Enumeration Date	:	01/23/2017
Last Update Date	:	01/26/2017

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