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NPI Code Detail

MEDICARE: MRS. JESSICA MAE MOODY PHYSICIAN ASSISTANT

MEDICARE: MRS. JESSICA MAE MOODY PHYSICIAN ASSISTANT
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
1363AS0400XSurgical Physician Assistant3474AZ
2363AM0700XMedical Physician Assistant3474AZ

General Provider Information

NPI Number : 1043349400
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JESSICA MAE MOODY PHYSICIAN ASSISTANT
Provider Business Mailing Address
First Line : 28727 N 20TH AVE
Second Line :
City : PHOENIX
State : AZ
Zip : 85085-0727
Country : US
Telephone Number : 520-780-0129
Fax Number :
Provider Business Practice Location Address
First Line : 11201 N TATUM BLVD STE 300
Second Line :
City : PHOENIX
State : AZ
Zip : 85028-6039
Country : US
Telephone Number : 480-900-3556
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/03/2007
Last Update Date : 03/31/2023

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