Provider Demographics
NPI:1235269556
Name:MOYER, KATHY JOANN (PA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:JOANN
Last Name:MOYER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:PA
Mailing Address - Zip Code:16684
Mailing Address - Country:US
Mailing Address - Phone:814-684-4600
Mailing Address - Fax:814-684-5557
Practice Address - Street 1:OLD ROUTE 220
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:PA
Practice Address - Zip Code:16684
Practice Address - Country:US
Practice Address - Phone:814-684-4600
Practice Address - Fax:814-684-5557
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001092L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009410110001Medicaid
PA0009410110001Medicaid
S40633Medicare UPIN