Provider Demographics
NPI:1275625295
Name:MORENO, LISA ANN (MS PA-C)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:MORENO
Suffix:
Gender:F
Credentials:MS PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 VETERANS MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504-7451
Mailing Address - Country:US
Mailing Address - Phone:254-981-1392
Mailing Address - Fax:612-970-5893
Practice Address - Street 1:1901 VETERANS MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-7451
Practice Address - Country:US
Practice Address - Phone:254-981-1392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9612363A00000X
TX10314363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant