1184645160 NPI number — DR. LAURA ELLEN MOFFAT MD

Table of content: DR. LAURA ELLEN MOFFAT MD (NPI 1184645160)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184645160 NPI number — DR. LAURA ELLEN MOFFAT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOFFAT
Provider First Name:
LAURA
Provider Middle Name:
ELLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROBESON
Provider Other First Name:
LAURA
Provider Other Middle Name:
ELLEN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184645160
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 19TH STREET
Provider Second Line Business Mailing Address:
SUITE 509
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37916-1853
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-524-3208
Provider Business Mailing Address Fax Number:
865-522-4322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 19TH STREET
Provider Second Line Business Practice Location Address:
SUITE 509
Provider Business Practice Location Address City Name:
KNOXVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37916-1853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-524-3208
Provider Business Practice Location Address Fax Number:
865-522-4322
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  37192 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: MD0000037192 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3886391 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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