Provider Demographics
NPI:1194595751
Name:MORENO, SANDIE (CPT)
Entity type:Individual
Prefix:
First Name:SANDIE
Middle Name:
Last Name:MORENO
Suffix:
Gender:F
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5915 SPRING GLEN DR
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-2729
Mailing Address - Country:US
Mailing Address - Phone:916-470-2439
Mailing Address - Fax:
Practice Address - Street 1:5915 SPRING GLEN DR
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-2729
Practice Address - Country:US
Practice Address - Phone:916-470-2439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-04
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA9C4Y2N4246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy