Basic Information
Provider Information | |||||||||
NPI: | 1770822330 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOHLIG | ||||||||
FirstName: | KRISTI | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1990 CONNECTICUT AVE S STE 100 | ||||||||
Address2: |   | ||||||||
City: | SARTELL | ||||||||
State: | MN | ||||||||
PostalCode: | 563772554 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2025755953 | ||||||||
FaxNumber: | 3202575596 | ||||||||
Practice Location | |||||||||
Address1: | 1990 CONNECTICUT AVE S STE 100 | ||||||||
Address2: |   | ||||||||
City: | SARTELL | ||||||||
State: | MN | ||||||||
PostalCode: | 563772554 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2025755953 | ||||||||
FaxNumber: | 3202575596 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/01/2013 | ||||||||
LastUpdateDate: | 08/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 923 | ND | N |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   | 363A00000X | 13049 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 923 | 01 | ND | ND LICENSURE | OTHER | 13049 | 01 | MN | MN LICENSE | OTHER |