Provider Demographics
NPI:1013435692
Name:MOSER, MIRANDA (RN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:MOSER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4737 COUNTY ROAD 101 # 119
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-2634
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19905 HIGHWAY 7 STE C1
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-8158
Practice Address - Country:US
Practice Address - Phone:612-616-4382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2431693163WG0000X, 163WI0500X, 163WW0000X, 163WX1500X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WW0000XNursing Service ProvidersRegistered NurseWound Care
No163WX1500XNursing Service ProvidersRegistered NurseOstomy Care