MEDICARE: DER MOUA RN

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	163W00000X	Registered Nurse	R197137-4	MN

General Provider Information

NPI Number	:	1275832347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DER MOUA RN

Provider Business Mailing Address
First Line	:	2499 RICE ST
Second Line	:	SUITE 132
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-3724
Country	:	US
Telephone Number	:	651-494-9058
Fax Number	:	651-494-6680

Provider Business Practice Location Address
First Line	:	2499 RICE ST
Second Line	:	SUITE 132
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-3724
Country	:	US
Telephone Number	:	651-494-9058
Fax Number	:	651-494-6680

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

Provider Enumeration Date	:	03/15/2011
Last Update Date	:	03/15/2011

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Directions to “ DER MOUA RN” Practice Location

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