Provider Demographics
NPI:1215118641
Name:MOXLEY, DEIRDRE T (PA-C)
Entity type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:T
Last Name:MOXLEY
Suffix:
Gender:F
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 1:207 W CRYSTAL VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92865-2212
Mailing Address - Country:US
Mailing Address - Phone:951-440-1501
Mailing Address - Fax:
Practice Address - Street 1:1950 SUNNYCREST DR
Practice Address - Street 2:SUITE 2300
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3638
Practice Address - Country:US
Practice Address - Phone:714-870-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18199363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical