Healthcare Provider Details

I. General information

NPI: 1275183063
Provider Name (Legal Business Name): BRITA M KOIVISTO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2214 LAKESHORE POINT DR NE
SAINT MICHAEL MN
55376-2805
US

IV. Provider business mailing address

2214 LAKESHORE POINT DR NE
SAINT MICHAEL MN
55376-2805
US

V. Phone/Fax

Practice location:
  • Phone: 763-478-1012
  • Fax:
Mailing address:
  • Phone: 763-478-1012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14007974-1206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13171
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: