Provider Demographics
NPI:1871299263
Name:MORENO, STEPHANIE MAKUMI (AGNP-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MAKUMI
Last Name:MORENO
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:WANGUI
Other - Last Name:MAKUMI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8240 N MOPAC EXPY STE 100
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8869
Mailing Address - Country:US
Mailing Address - Phone:512-610-5339
Mailing Address - Fax:512-407-9010
Practice Address - Street 1:1900 SCENIC DR STE 1114
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7724
Practice Address - Country:US
Practice Address - Phone:512-248-2200
Practice Address - Fax:512-248-1950
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1108827363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology