Healthcare Provider Details

I. General information

NPI: 1922403401
Provider Name (Legal Business Name): DUNCAN LESLIE MOFFITT P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2014
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MEDICAL DRIVE SUITE 701
LAGRANGE GA
30240
US

IV. Provider business mailing address

300 MEDICAL DRIVE SUITE 701
LAGRANGE GA
30240
US

V. Phone/Fax

Practice location:
  • Phone: 706-882-8971
  • Fax: 706-882-8991
Mailing address:
  • Phone: 706-882-8971
  • Fax: 706-882-8991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number007416
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007416
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: