Healthcare Provider Details

I. General information

NPI: 1225121247
Provider Name (Legal Business Name): DARRELL KENNETH MOYER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13911 RIDGEDALE DRIVE SUITE 350
MINNETONKA MN
55305
US

IV. Provider business mailing address

4000 LATOKA VIEW LANE SW
ALEXANDRIA MN
56308-4906
US

V. Phone/Fax

Practice location:
  • Phone: 952-932-0998
  • Fax: 952-932-7122
Mailing address:
  • Phone: 952-932-9012
  • Fax: 952-932-7122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR0860554
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: