Provider Demographics
NPI:1700844073
Name:MOBERG, DENNIS MILES (CRNA)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:MILES
Last Name:MOBERG
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3756 ROSCOMMON S
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-4742
Mailing Address - Country:US
Mailing Address - Phone:706-284-5670
Mailing Address - Fax:
Practice Address - Street 1:3651 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6521
Practice Address - Country:US
Practice Address - Phone:706-855-9860
Practice Address - Fax:706-860-7124
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN077262367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA430077077OtherRAILROAD MEDICARE
SCAN0562Medicaid
GA000616228BMedicaid
GA10065595OtherAMERIGROUP
GA43ZCCBD08Medicare PIN
SCAN0562Medicaid