Healthcare Provider Details

I. General information

NPI: 1043988298
Provider Name (Legal Business Name): COLLIN ARNOLD MOEN CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W 22ND ST
SIOUX FALLS SD
57105-1305
US

IV. Provider business mailing address

8808 W 22ND ST
SIOUX FALLS SD
57106-5848
US

V. Phone/Fax

Practice location:
  • Phone: 605-336-3230
  • Fax:
Mailing address:
  • Phone: 605-770-2885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCP002137
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR049685
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: