Healthcare Provider Details

I. General information

NPI: 1225595911
Provider Name (Legal Business Name): PAETON MOYLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PAETON LARSON

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 MOUNT RUSHMORE RD
RAPID CITY SD
57701-5474
US

IV. Provider business mailing address

5713 BENDT DR
RAPID CITY SD
57702-9618
US

V. Phone/Fax

Practice location:
  • Phone: 605-342-3280
  • Fax:
Mailing address:
  • Phone: 605-393-7051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1181
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: