Provider Demographics
NPI:1225121247
Name:MOYER, DARRELL KENNETH (CRNA)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:KENNETH
Last Name:MOYER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 LATOKA VIEW LANE SW
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-4906
Mailing Address - Country:US
Mailing Address - Phone:952-932-9012
Mailing Address - Fax:952-932-7122
Practice Address - Street 1:13911 RIDGEDALE DRIVE
Practice Address - Street 2:SUITE 350
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305
Practice Address - Country:US
Practice Address - Phone:952-932-0998
Practice Address - Fax:952-932-7122
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0860554367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered