Provider Demographics
NPI:1225595911
Name:MOYLE, PAETON (PA-C)
Entity type:Individual
Prefix:
First Name:PAETON
Middle Name:
Last Name:MOYLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PAETON
Other - Middle Name:
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5713 BENDT DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-9618
Mailing Address - Country:US
Mailing Address - Phone:605-393-7051
Mailing Address - Fax:
Practice Address - Street 1:2820 MOUNT RUSHMORE RD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5474
Practice Address - Country:US
Practice Address - Phone:605-342-3280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty