Healthcare Provider Details

I. General information

NPI: 1184069304
Provider Name (Legal Business Name): KRISTINA KAY THISSEN PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21395 JOHN MILLESS DR
ROGERS MN
55374-4402
US

IV. Provider business mailing address

21395 JOHN MILLESS DR
ROGERS MN
55374-4402
US

V. Phone/Fax

Practice location:
  • Phone: 763-504-6400
  • Fax: 763-504-6410
Mailing address:
  • Phone: 763-504-6400
  • Fax: 763-504-6410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: