Provider Demographics
NPI:1154984706
Name:MORENO, ANTONIO
Entity type:Individual
Prefix:
First Name:ANTONIO
Middle Name:
Last Name:MORENO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25590 PROSPECT AVE APT 25H
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3149
Mailing Address - Country:US
Mailing Address - Phone:323-440-1388
Mailing Address - Fax:
Practice Address - Street 1:2101 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4836
Practice Address - Country:US
Practice Address - Phone:909-883-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-18
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001104367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered