1831105287 NPI number — MS. NOREEN TRESA JACK-MOONEY PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831105287 NPI number — MS. NOREEN TRESA JACK-MOONEY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACK-MOONEY
Provider First Name:
NOREEN
Provider Middle Name:
TRESA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACK-MOONEY
Provider Other First Name:
NOREEN
Provider Other Middle Name:
TRESA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1831105287
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2050 S BLOSSER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA MARIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93458-7310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-361-8028
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
80 B VETERANS BLVD
Provider Second Line Business Practice Location Address:
I-40, EXIT 102
Provider Business Practice Location Address City Name:
ACOMA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-552-5300
Provider Business Practice Location Address Fax Number:
505-552-5828
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  AMD-276 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: H3451 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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