Provider Demographics
NPI:1629000682
Name:EAGAN CHILD AND FAMILY CARE, P.A.
Entity Type:Organization
Organization Name:EAGAN CHILD AND FAMILY CARE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPNP
Authorized Official - Phone:651-209-8640
Mailing Address - Street 1:4178 KNOB DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2888
Mailing Address - Country:US
Mailing Address - Phone:651-209-8640
Mailing Address - Fax:651-209-8690
Practice Address - Street 1:4178 KNOB DR
Practice Address - Street 2:SUITE A
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2888
Practice Address - Country:US
Practice Address - Phone:651-209-8640
Practice Address - Fax:651-209-8690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1650207Q00000X, 208000000X, 363LF0000X, 363LP0200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Not Answered363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Multi-Specialty
Not Answered363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty