MEDICARE: MR. CARLOS JULIO MORENO

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	363A00000X	Physician Assistant	PA9102549	FL
2	363A00000X	Physician Assistant	006320	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA9102549	OTHER	FL	PA LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	006320	OTHER	GA	STATE LICENSE - PHYSICIAN ASSISTANT
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477615862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARLOS JULIO MORENO

Provider Business Mailing Address
First Line	:	690 DALLAS HWY
Second Line	:	SUITE 101
City	:	VILLA RICA
State	:	GA
Zip	:	30180-1264
Country	:	US
Telephone Number	:	770-459-0620
Fax Number	:	770-456-7604

Provider Business Practice Location Address
First Line	:	690 DALLAS HWY
Second Line	:	SUITE 101
City	:	VILLA RICA
State	:	GA
Zip	:	30180-1264
Country	:	US
Telephone Number	:	770-459-0620
Fax Number	:	770-456-7604

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	12/19/2011

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Directions to “ MR. CARLOS JULIO MORENO ” Practice Location

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