MEDICARE: JEFFREY LANG MOULTON PA-C

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	363A00000X	Physician Assistant	3652	GA
2	363AM0700X	Medical Physician Assistant	3652	GA
3	363AS0400X	Surgical Physician Assistant	3652	GA
4	363AM0700X	Medical Physician Assistant	PA9110559	FL

General Provider Information

NPI Number	:	1518009612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY LANG MOULTON PA-C

Provider Business Mailing Address
First Line	:	2400 BELLEVUE RD
Second Line	:	STE 21A
City	:	DUBLIN
State	:	GA
Zip	:	31021-2890
Country	:	US
Telephone Number	:	478-328-0281
Fax Number	:	478-328-0438

Provider Business Practice Location Address
First Line	:	4200 N ARMENIA AVE STE 1-2
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6438
Country	:	US
Telephone Number	:	813-877-4811
Fax Number	:	813-872-8978

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

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	09/15/2020

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