MEDICARE: CASEY MOFFITT

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
1	390200000X	Student in an Organized Health Care Education/Training Program		PA

General Provider Information

NPI Number	:	1144979295
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY MOFFITT

Provider Business Mailing Address
First Line	:	1025 WALNUT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5001
Country	:	US
Telephone Number	:	610-241-5466
Fax Number	:

Provider Business Practice Location Address
First Line	:	1025 WALNUT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-5001
Country	:	US
Telephone Number	:	610-241-5466
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/23/2022
Last Update Date	:	03/23/2022

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