Basic Information
| Provider Information | |||||||||
| NPI: | 1114942216 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRAY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANSEN | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | JOE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 811 2ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LITTLE FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563453559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206317000 | ||||||||
| FaxNumber: | 3206320534 | ||||||||
| Practice Location | |||||||||
| Address1: | 811 2ND ST SE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LITTLE FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563453559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206317000 | ||||||||
| FaxNumber: | 3206320534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 40710 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | A019 | 01 | MN | TRICARE | OTHER | 506380900 | 05 | MN | MEDICAID | HP29219 | 01 | HEALTH PARTNERS | OTHER | 18F30KR | 01 | MN | BCBS OF MINNESOTA | OTHER | 0105822 | 01 | MEDICA | OTHER | 151305C736 | 01 | MN | UCARE MINNESOTA | OTHER | 992491 | 01 | AMERICA'S PPO | OTHER | NA9231017076 | 01 | PREFERRED ONE | OTHER |