Healthcare Provider Details

I. General information

NPI: 1104163369
Provider Name (Legal Business Name): KRISTA MARIE SKOGLUND P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2013
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11850 BLACKFOOT ST NW SUITE 490
COON RAPIDS MN
55433-2578
US

IV. Provider business mailing address

11850 BLACKFOOT ST NW SUITE 490
COON RAPIDS MN
55433-2578
US

V. Phone/Fax

Practice location:
  • Phone: 763-427-1137
  • Fax: 763-427-4643
Mailing address:
  • Phone: 763-427-1137
  • Fax: 763-427-4643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number11298
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11298
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: