Provider Demographics
NPI:1922034933
Name:MOEN, GRETCHEN A (CPNP)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:A
Last Name:MOEN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4734 WESTMINSTER CIR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55122-2756
Mailing Address - Country:US
Mailing Address - Phone:651-456-0127
Mailing Address - Fax:
Practice Address - Street 1:2530 HORIZON DR
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-3091
Practice Address - Country:US
Practice Address - Phone:651-209-8640
Practice Address - Fax:651-209-8690
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1162002363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01143Medicare UPIN