Provider Demographics
NPI:1720461759
Name:MOELLER, TAWNYA M (CST)
Entity Type:Individual
Prefix:
First Name:TAWNYA
Middle Name:M
Last Name:MOELLER
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:901 N CURTIS RD
Mailing Address - Street 2:STE 304
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-1338
Mailing Address - Country:US
Mailing Address - Phone:208-342-4263
Mailing Address - Fax:208-375-0597
Practice Address - Street 1:901 N CURTIS RD
Practice Address - Street 2:STE 304
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1338
Practice Address - Country:US
Practice Address - Phone:208-342-4263
Practice Address - Fax:208-375-0597
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ID122512246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist