Provider Demographics
NPI:1801248976
Name:MOFFITT, MELINDA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MELINDA
Middle Name:
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:366 CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44627-9224
Mailing Address - Country:US
Mailing Address - Phone:234-249-2367
Mailing Address - Fax:
Practice Address - Street 1:3050 REGENT BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-3196
Practice Address - Country:US
Practice Address - Phone:214-689-8109
Practice Address - Fax:877-457-3988
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant