MEDICARE: MR. DANIEL LEE MOFFAT P.A.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	1466	AZ

General Provider Information

NPI Number	:	1659331833
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DANIEL LEE MOFFAT P.A.C.

Provider Business Mailing Address
First Line	:	500 N US HIGHWAY 89
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86313-5001
Country	:	US
Telephone Number	:	928-445-4860
Fax Number	:	928-717-7553

Provider Business Practice Location Address
First Line	:	500 N US HIGHWAY 89
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86313-5001
Country	:	US
Telephone Number	:	928-445-4860
Fax Number	:	928-717-7553

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	07/08/2007

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