Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 2084N0402X | Child Neurologist | 107634 | MN |
Y | 2084N0402X | Child Neurologist | 58414 | MN |
NPI | 1154563401 |
---|---|
Provider Name | Amanda M Moen |
First Address | Saint Paul, MN 55101-2507 |
Second Address | Minneapolis, MN 55454-1450 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/04/2009 |
Last Update Date | 04/04/2019 |