MEDICARE: TONY L. MOFFITT NP

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	363L00000X	Nurse Practitioner	ARNP1871332	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417924754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TONY L. MOFFITT NP

Provider Business Mailing Address
First Line	:	1624 KING JAMES CT
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2923
Country	:	US
Telephone Number	:	863-670-0114
Fax Number	:

Provider Business Practice Location Address
First Line	:	3810 DRANE FIELD RD
Second Line	:	UNIT 15
City	:	LAKELAND
State	:	FL
Zip	:	33811-1204
Country	:	US
Telephone Number	:	863-646-8468
Fax Number	:	863-533-0333

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

Provider Enumeration Date	:	03/07/2006
Last Update Date	:	07/09/2007

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