Healthcare Provider Details

I. General information

NPI: 1962439547
Provider Name (Legal Business Name): KRISTOFER MICHAEL WALLMAN MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 PENN ST
FOLEY MN
56329-8700
US

IV. Provider business mailing address

22957 27TH AVE
SAINT AUGUSTA MN
56301-2201
US

V. Phone/Fax

Practice location:
  • Phone: 320-774-3636
  • Fax: 320-774-3360
Mailing address:
  • Phone: 218-341-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9285
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: