Healthcare Provider Details

I. General information

NPI: 1447406426
Provider Name (Legal Business Name): THOMAS P. MORETTI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2008
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ARCADE AVE SUITE 400
ELKHART IN
46514-2477
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-522-2284
  • Fax: 574-522-3952
Mailing address:
  • Phone: 574-647-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001037A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: