Provider Demographics
NPI:1275107179
Name:MOUA, TONY
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:MOUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 RIVOLI ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-4422
Mailing Address - Country:US
Mailing Address - Phone:612-702-4202
Mailing Address - Fax:
Practice Address - Street 1:676 RIVOLI ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-4422
Practice Address - Country:US
Practice Address - Phone:612-702-4202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA2625225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant