Provider Demographics
NPI:1184688863
Name:MOSS, RUBY WAGA (CRNA)
Entity type:Individual
Prefix:
First Name:RUBY
Middle Name:WAGA
Last Name:MOSS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4633 PARKCLIFF DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2143
Mailing Address - Country:US
Mailing Address - Phone:651-405-9652
Mailing Address - Fax:
Practice Address - Street 1:1544 SHELDON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-2331
Practice Address - Country:US
Practice Address - Phone:651-646-3091
Practice Address - Fax:651-646-3124
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 091572-6163W00000X
MN049536367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN443720900Medicaid