Healthcare Provider Details

I. General information

NPI: 1215118641
Provider Name (Legal Business Name): DEIRDRE T MOXLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2007
Last Update Date: 11/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 SUNNYCREST DR SUITE 2300
FULLERTON CA
92835-3638
US

IV. Provider business mailing address

207 W CRYSTAL VIEW AVE
ORANGE CA
92865-2212
US

V. Phone/Fax

Practice location:
  • Phone: 714-870-4772
  • Fax:
Mailing address:
  • Phone: 951-440-1501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number18199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: