MEDICARE: MR. MARK MOFFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MARK1961	OTHER	MN	PROSTHETICS

General Provider Information

NPI Number	:	1134354137
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK MOFFA

Provider Business Mailing Address
First Line	:	1903 COUNTY ROAD D.
Second Line	:
City	:	ARDEN HILLS
State	:	MN
Zip	:	55112
Country	:	US
Telephone Number	:	612-701-9549
Fax Number	:

Provider Business Practice Location Address
First Line	:	1903 COUNTY ROAD D W
Second Line	:
City	:	ARDEN HILLS
State	:	MN
Zip	:	55112-3512
Country	:	US
Telephone Number	:	612-701-9549
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	05/19/2009

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Directions to “ MR. MARK MOFFA ” Practice Location

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