Provider Demographics
NPI:1770738239
Name:MOFFITT, MICHELLE B (PA C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:B
Last Name:MOFFITT
Suffix:
Gender:
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE # MC4903
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-9800
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:5950 SR 6
Practice Address - Street 2:4TH FLOOR
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-7905
Practice Address - Country:US
Practice Address - Phone:570-836-6808
Practice Address - Fax:570-836-5536
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA053712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031977260001Medicaid
PA1031977260001Medicaid