Healthcare Provider Details

I. General information

NPI: 1245876796
Provider Name (Legal Business Name): MICHAEL KITTOK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2019
Last Update Date: 12/22/2022
Certification Date: 12/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11475 ROBINSON DR NW
COON RAPIDS MN
55433-7432
US

IV. Provider business mailing address

11475 ROBINSON DR NW
COON RAPIDS MN
55433-7432
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13578
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: