Healthcare Provider Details

I. General information

NPI: 1275171795
Provider Name (Legal Business Name): KEITH FERTEY MOY PA STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2019
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 3RD ST NW
ELK RIVER MN
55330-1445
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-4800
  • Fax: 763-587-4845
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13657
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: