Healthcare Provider Details

I. General information

NPI: 1013435692
Provider Name (Legal Business Name): MIRANDA MOSER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19905 HIGHWAY 7 STE C1
EXCELSIOR MN
55331-8158
US

IV. Provider business mailing address

4737 COUNTY ROAD 101 # 119
MINNETONKA MN
55345-2634
US

V. Phone/Fax

Practice location:
  • Phone: 612-616-4382
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number2431693
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number2431693
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number2431693
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code163WX1500X
TaxonomyOstomy Care Registered Nurse
License Number2431693
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2431693
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: