Provider Demographics
NPI:1861607145
Name:MORENO, JUAN FERNANDO (PA)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:FERNANDO
Last Name:MORENO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BAYLOR PLZ # BCM285
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1504 TAUB LOOP
Practice Address - Street 2:DEPT OF UROLOGY
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1608
Practice Address - Country:US
Practice Address - Phone:713-873-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00738111Medicare PIN
TX8L17093Medicare PIN
TX8B9756Medicare PIN
TX8L24365Medicare PIN