MEDICARE: MS. KRISTEN J RUSSEK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	7688	MN

General Provider Information

NPI Number	:	1265532394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTEN J RUSSEK PT

Provider Business Mailing Address
First Line	:	1155 COUNTY ROAD E E STE 120
Second Line	:
City	:	VADNAIS HTS
State	:	MN
Zip	:	55110-5191
Country	:	US
Telephone Number	:	651-241-1464
Fax Number	:

Provider Business Practice Location Address
First Line	:	1155 COUNTY ROAD E E STE 120
Second Line	:
City	:	VADNAIS HTS
State	:	MN
Zip	:	55110-5191
Country	:	US
Telephone Number	:	651-241-1464
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	02/15/2022

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