Basic Information
| Provider Information | |||||||||
| NPI: | 1609293711 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOATS | ||||||||
| FirstName: | KELLI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5055 E BROADWAY BLVD | ||||||||
| Address2: | A-100 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857113640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203270460 | ||||||||
| FaxNumber: | 5207950225 | ||||||||
| Practice Location | |||||||||
| Address1: | 3043 W INA RD | ||||||||
| Address2: | #115 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857412107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207977070 | ||||||||
| FaxNumber: | 5207977077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2014 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP5448 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.