1144813890 NPI number — EDUARDO DANIEL MORENO MANDUJANO 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 1144813890 NPI number — EDUARDO DANIEL MORENO MANDUJANO PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORENO MANDUJANO
Provider First Name:
EDUARDO
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144813890
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/26/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1089
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OMEGA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31775-1089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-589-1962
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2615 N MONROE ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TALLAHASSEE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32303-4027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-558-6126
Provider Business Practice Location Address Fax Number:
850-220-4461
Provider Enumeration Date:
02/13/2021

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: 363A00000X , with the licence number:  PA9115758 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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