Basic Information
Provider Information | |||||||||
NPI: | 1386749919 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOFFAT | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8681 EAGLE POINT BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKE ELMO | ||||||||
State: | MN | ||||||||
PostalCode: | 550428628 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6512518021 | ||||||||
FaxNumber: | 6512518050 | ||||||||
Practice Location | |||||||||
Address1: | 69 EXCHANGE ST W | ||||||||
Address2: |   | ||||||||
City: | SAINT PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 551021004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6517350501 | ||||||||
FaxNumber: | 6517351870 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/14/2006 | ||||||||
LastUpdateDate: | 10/05/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R1431611 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 415968300 | 05 | MN |   | MEDICAID |