Provider Demographics
NPI:1447406426
Name:MORETTI, THOMAS P (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:P
Last Name:MORETTI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:500 ARCADE AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2477
Practice Address - Country:US
Practice Address - Phone:574-522-2284
Practice Address - Fax:574-522-3952
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001037A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01153860OtherRR MEDICARE
IN300008492Medicaid
IN000000634026OtherBCBS BMG ORTHOPEDIC TRAUMA
IN231860DMedicare PIN