Individual
MR. CARLOS JULIO MORENO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
690 DALLAS HWY, SUITE 101, VILLA RICA, GA 30180-1264
(770) 459-0620
(770) 456-7604
Mailing address
690 DALLAS HWY, SUITE 101, VILLA RICA, GA 30180-1264
(770) 459-0620
(770) 456-7604
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
006320
GA
363A00000X
Physician Assistant
PA9102549
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
006320
STATE LICENSE - PHYSICIAN ASSISTANT
GA
05
—
292140500
—
FL
01
—
PA9102549
PA LICENSE
FL
05
—
PENDING
—
GA
Enumeration date
12/14/2006
Last updated
12/19/2011
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