Provider Demographics
NPI:1275171795
Name:MOY, KEITH FERTEY (PA STUDENT)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:FERTEY
Last Name:MOY
Suffix:
Gender:M
Credentials:PA STUDENT
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Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 3RD ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1445
Practice Address - Country:US
Practice Address - Phone:763-587-4800
Practice Address - Fax:763-587-4845
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2021-09-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN13657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant