Provider Demographics
NPI:1417924754
Name:MOFFITT, TONY L (NP)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:L
Last Name:MOFFITT
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 KING JAMES CT
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2923
Mailing Address - Country:US
Mailing Address - Phone:863-670-0114
Mailing Address - Fax:
Practice Address - Street 1:3810 DRANE FIELD RD
Practice Address - Street 2:UNIT 15
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33811-1204
Practice Address - Country:US
Practice Address - Phone:863-646-8468
Practice Address - Fax:863-533-0333
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1871332363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5490BMedicare ID - Type UnspecifiedMEDICARE
FLP30953Medicare UPIN