MEDICARE: DR. CARLOS E HERNANDEZ MORENO MD

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	208000000X	Pediatrics Physician	7536	PR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	29594	OTHER	PR	T-SSS

General Provider Information

NPI Number	:	1386655058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS E HERNANDEZ MORENO MD

Provider Business Mailing Address
First Line	:	PO BOX 1310
Second Line	:	PO BOX 1310
City	:	RIVERTON
State	:	WY
Zip	:	82501
Country	:	UM
Telephone Number	:	787-895-0045
Fax Number	:	787-817-2571

Provider Business Practice Location Address
First Line	:	14 GREAT PLAINS ROAD
Second Line	:
City	:	ARAPAHOE
State	:	WY
Zip	:	82510-0014
Country	:	US
Telephone Number	:	307-856-9281
Fax Number	:	307-463-4489

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

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	08/10/2020

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