Provider Demographics
NPI:1407519630
Name:MORANGA, EDWIN O (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:O
Last Name:MORANGA
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12707 INGLEWOOD AVE S
Mailing Address - Street 2:
Mailing Address - City:SAVAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55378-1576
Mailing Address - Country:US
Mailing Address - Phone:616-856-0163
Mailing Address - Fax:
Practice Address - Street 1:12707 INGLEWOOD AVE S
Practice Address - Street 2:
Practice Address - City:SAVAGE
Practice Address - State:MN
Practice Address - Zip Code:55378-1576
Practice Address - Country:US
Practice Address - Phone:616-856-0163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-14
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2206640163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN933217Medicaid