Provider Demographics
NPI:1518009612
Name:MOULTON, JEFFREY LANG (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LANG
Last Name:MOULTON
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 1:2400 BELLEVUE RD
Mailing Address - Street 2:STE 21A
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2890
Mailing Address - Country:US
Mailing Address - Phone:478-328-0281
Mailing Address - Fax:478-328-0438
Practice Address - Street 1:4200 N ARMENIA AVE STE 1-2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6438
Practice Address - Country:US
Practice Address - Phone:813-877-4811
Practice Address - Fax:813-872-8978
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3652363A00000X, 363AM0700X, 363AS0400X
FLPA9110559363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical