Provider Demographics
NPI:1851177505
Name:MOFFO, KATELYN ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:MOFFO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2105 BRAXTON LN STE 101
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-2862
Mailing Address - Country:US
Mailing Address - Phone:336-333-6306
Mailing Address - Fax:336-333-6309
Practice Address - Street 1:2105 BRAXTON LN STE 101
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-2862
Practice Address - Country:US
Practice Address - Phone:336-333-6306
Practice Address - Fax:336-333-6309
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-13501363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant