Provider Demographics
NPI:1386364784
Name:MOFFATT, ADAM DEREK-ALAN (PA)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:DEREK-ALAN
Last Name:MOFFATT
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 1:1951 S OTSEGO AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-8489
Mailing Address - Country:US
Mailing Address - Phone:989-732-3284
Mailing Address - Fax:989-732-6395
Practice Address - Street 1:1951 S OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-8489
Practice Address - Country:US
Practice Address - Phone:989-732-3284
Practice Address - Fax:989-732-6395
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601011331TMP22363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant