Healthcare Provider Details

I. General information

NPI: 1053458752
Provider Name (Legal Business Name): SARAH JANE KOTTKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 11/09/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SMITH AVE N
SAINT PAUL MN
55102-2344
US

IV. Provider business mailing address

333 SMITH AVE N
SAINT PAUL MN
55102-2344
US

V. Phone/Fax

Practice location:
  • Phone: 651-241-8860
  • Fax:
Mailing address:
  • Phone: 651-241-8860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number49170
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: