Provider Demographics
NPI:1285216671
Name:MORENO, JOSHUA ENRIQUE
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:ENRIQUE
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 1:1794 LAKE WATEREE DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-8178
Mailing Address - Country:US
Mailing Address - Phone:801-808-2913
Mailing Address - Fax:
Practice Address - Street 1:1005 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2707
Practice Address - Country:US
Practice Address - Phone:843-777-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-25
Last Update Date:2021-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant