Provider Demographics
NPI:1841220043
Name:MOFFETT, JOHN SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:MOFFETT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1902 W 20TH LN
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-8847
Mailing Address - Country:US
Mailing Address - Phone:928-329-9515
Mailing Address - Fax:
Practice Address - Street 1:2400 S AVENUE A
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-7127
Practice Address - Country:US
Practice Address - Phone:928-336-7100
Practice Address - Fax:928-336-7508
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2780363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZPA2780Medicaid
AZP22567Medicare UPIN
AZ106818Medicare ID - Type Unspecified