Healthcare Provider Details

I. General information

NPI: 1306149539
Provider Name (Legal Business Name): KATHRYN SUSAN EISENMENGER FUENTES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHRYN SUSAN EISENMENGER

II. Dates (important events)

Enumeration Date: 12/09/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2854 HIGHWAY 55 SUITE 130
EAGAN MN
55121-2156
US

IV. Provider business mailing address

2854 HIGHWAY 55 SUITE 130
EAGAN MN
55121-2156
US

V. Phone/Fax

Practice location:
  • Phone: 651-842-3320
  • Fax: 651-224-5273
Mailing address:
  • Phone: 651-842-3320
  • Fax: 651-224-5273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1514
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: