Provider Demographics
NPI:1841754389
Name:MOBERG, KAREN (MED, ATC)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MOBERG
Suffix:
Gender:F
Credentials:MED, ATC
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:
Other - Last Name:ROTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, ATC
Mailing Address - Street 1:8700 COLLEGE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:ST BONIFACIUS
Mailing Address - State:MN
Mailing Address - Zip Code:55375-9001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8700 COLLEGE VIEW DR
Practice Address - Street 2:
Practice Address - City:ST BONIFACIUS
Practice Address - State:MN
Practice Address - Zip Code:55375-9001
Practice Address - Country:US
Practice Address - Phone:952-446-4429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN21602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer