Provider Demographics
NPI:1417724402
Name:FONSECA-MORENO, MIGUEL
Entity type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:FONSECA-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 1:80 W MARYLAND AVE APT 207
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-1266
Mailing Address - Country:US
Mailing Address - Phone:480-686-3301
Mailing Address - Fax:
Practice Address - Street 1:42104 N VENTURE DR STE D118
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-3837
Practice Address - Country:US
Practice Address - Phone:623-505-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-08
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10680207R00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant