Provider Demographics
NPI:1063911469
Name:MOE, JUSTIN ROBERT
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:MOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13355 GEORGE WEBER DR STE B
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-4864
Mailing Address - Country:US
Mailing Address - Phone:612-554-0740
Mailing Address - Fax:612-278-2022
Practice Address - Street 1:13355 GEORGE WEBER DR STE B
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4864
Practice Address - Country:US
Practice Address - Phone:612-554-0740
Practice Address - Fax:612-554-0740
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-2096708163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health