Provider Demographics
NPI:1497070080
Name:MOELLER, JAMES BRIAN (MT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:BRIAN
Last Name:MOELLER
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LAKE TRAVERSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262
Mailing Address - Country:US
Mailing Address - Phone:605-742-3792
Mailing Address - Fax:
Practice Address - Street 1:100 LAKE TRAVERSE DRIVE
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262
Practice Address - Country:US
Practice Address - Phone:605-742-3792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD189324246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist