Healthcare Provider Details

I. General information

NPI: 1083551147
Provider Name (Legal Business Name): KIERAN RETTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 HIGHLAND BLVD
MOUND MN
55364-8537
US

IV. Provider business mailing address

3040 HIGHLAND BLVD
MOUND MN
55364-8537
US

V. Phone/Fax

Practice location:
  • Phone: 612-387-1713
  • Fax:
Mailing address:
  • Phone: 612-387-1713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: