Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2086S0127X | Trauma Surgeon | 12002 | MN |
NPI | 1518330570 |
---|---|
Provider Name | Colleen Mooney |
First Address | Robbinsdale, MN 55422-2926 |
Second Address | Saint Paul, MN 55102-2388 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/11/2015 |
Last Update Date | 21/02/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
363A00000X | (05) | MN |