Basic Information
| Provider Information | |||||||||
| NPI: | 1306149539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EISENMENGER FUENTES | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EISENMENGER | ||||||||
| OtherFirstName: | KATHRYN | ||||||||
| OtherMiddleName: | SUSAN | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2854 HIGHWAY 55 | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551212156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518423320 | ||||||||
| FaxNumber: | 6512245273 | ||||||||
| Practice Location | |||||||||
| Address1: | 2854 HIGHWAY 55 | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | EAGAN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551212156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6518423320 | ||||||||
| FaxNumber: | 6512245273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2010 | ||||||||
| LastUpdateDate: | 12/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1514 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.