Healthcare Provider Details

I. General information

NPI: 1184688863
Provider Name (Legal Business Name): RUBY WAGA MOSS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2006
Last Update Date: 07/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1544 SHELDON ST
SAINT PAUL MN
55108-2331
US

IV. Provider business mailing address

4633 PARKCLIFF DR
EAGAN MN
55123-2143
US

V. Phone/Fax

Practice location:
  • Phone: 651-646-3091
  • Fax: 651-646-3124
Mailing address:
  • Phone: 651-405-9652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 091572-6
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number049536
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: