Basic Information
| Provider Information | |||||||||
| NPI: | 1356535926 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAEL | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3833 COON RAPIDS BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7633024338 | ||||||||
| Practice Location | |||||||||
| Address1: | 3833 COON RAPIDS BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COON RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554332697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7634278320 | ||||||||
| FaxNumber: | 7633024338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2007 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 10341 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1052601 | 01 | MN | PREFERRED ONE | OTHER | HP83447 | 01 | MN | HEALTHPARTNERS | OTHER | 0128253 | 01 | MN | MEDICA | OTHER | 0R850MI | 01 | MN | BCBS | OTHER | 1356535926 | 05 | MN | MEDICAID | 1356535926 | 01 | MN | AMERICA'S PPO | OTHER | 139780C029 | 01 | MN | UCARE | OTHER | 41944100 | 05 | WI | MEDICAID |