Healthcare Provider Details

I. General information

NPI: 1205767597
Provider Name (Legal Business Name): TEAGAN AUDREY KAUTZMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 COMMERCE DR STE 200
WOODBURY MN
55125-4925
US

IV. Provider business mailing address

6594 ORCHID LN N
MAPLE GROVE MN
55311-3261
US

V. Phone/Fax

Practice location:
  • Phone: 651-968-5639
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15753
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: