Provider Demographics
NPI:1386484889
Name:SANTIAGO MORENO, MARCOS
Entity type:Individual
Prefix:
First Name:MARCOS
Middle Name:
Last Name:SANTIAGO 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 1:5125 CASTELLO DR FL 34103
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34103-1902
Mailing Address - Country:US
Mailing Address - Phone:813-590-6717
Mailing Address - Fax:
Practice Address - Street 1:5125 CASTELLO DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-1902
Practice Address - Country:US
Practice Address - Phone:813-590-6717
Practice Address - Fax:813-990-0222
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-31
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11033051363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health