MEDICARE: JENNA LYNN MOSCHEROSCH MS PAC

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	363AM0700X	Medical Physician Assistant	5601005802	MI
2	363AM0700X	Medical Physician Assistant	11785	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1156321600	OTHER	MI	BCBS IND

General Provider Information

NPI Number	:	1356653760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA LYNN MOSCHEROSCH MS PAC

Provider Business Mailing Address
First Line	:	8170 33RD AVE S # MS 21110Q
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55425-4516
Country	:	US
Telephone Number	:	952-853-8800
Fax Number	:

Provider Business Practice Location Address
First Line	:	5366 386TH ST NE
Second Line	:
City	:	NORTH BRANCH
State	:	MN
Zip	:	55056-5833
Country	:	US
Telephone Number	:	651-674-8353
Fax Number	:

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

Provider Enumeration Date	:	07/14/2010
Last Update Date	:	03/17/2018

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