=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689638066
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA A. MOEN M.S., ATC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2006
-----------------------------------------------------
Last Update Date | 12/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10961 CLUBWEST PKWY NE SUITE 200
-----------------------------------------------------
City | BLAINE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-528-2992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 349 120TH CIR NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55448-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-930-9631
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096-001286
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 2666
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------