Provider Demographics
NPI:1669404380
Name:MORENO HARRIS, BONNIE MICHELLE (PA)
Entity type:Individual
Prefix:MR
First Name:BONNIE
Middle Name:MICHELLE
Last Name:MORENO HARRIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2495 PINE AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-3029
Mailing Address - Country:US
Mailing Address - Phone:562-477-4244
Mailing Address - Fax:323-726-9789
Practice Address - Street 1:2495 PINE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-3029
Practice Address - Country:US
Practice Address - Phone:562-477-4244
Practice Address - Fax:323-726-9789
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14731363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical