Healthcare Provider Details

I. General information

NPI: 1063893220
Provider Name (Legal Business Name): PATRICK J MOEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2015
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN RD STE 301
SAINT LOUIS MO
63136-6132
US

IV. Provider business mailing address

11125 DUNN RD STE 301
SAINT LOUIS MO
63136-6132
US

V. Phone/Fax

Practice location:
  • Phone: 314-953-8250
  • Fax:
Mailing address:
  • Phone: 314-953-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME148643
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2022034935
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: