1649374646 NPI number — DR. WALTER WYATT MOE MD

Table of content: DR. WALTER WYATT MOE MD (NPI 1649374646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649374646 NPI number — DR. WALTER WYATT MOE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOE
Provider First Name:
WALTER
Provider Middle Name:
WYATT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649374646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1230 SPRUCE PLACE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUND
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55364-9626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-471-7022
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 VETERANS DRIVE
Provider Second Line Business Practice Location Address:
VETERANS AFFAIRS MEDICAL CENTER
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-725-2000
Provider Business Practice Location Address Fax Number:
612-467-5971
Provider Enumeration Date:
09/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  14262 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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