Provider Demographics
NPI:1306686464
Name:MOE, LAURA JEANNE (OD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEANNE
Last Name:MOE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7312 HILLTON RD
Mailing Address - Street 2:
Mailing Address - City:ROYALTON
Mailing Address - State:MN
Mailing Address - Zip Code:56373-4006
Mailing Address - Country:US
Mailing Address - Phone:320-630-8757
Mailing Address - Fax:
Practice Address - Street 1:510 FREEPORT AVE NW STE C
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-3007
Practice Address - Country:US
Practice Address - Phone:763-441-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN3937152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program