Healthcare Provider Details

I. General information

NPI: 1639854532
Provider Name (Legal Business Name): PATRICK KOISTINEN CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 4TH ST SE
HURON SD
57350-2509
US

IV. Provider business mailing address

44467 194TH ST
LAKE NORDEN SD
57248-5808
US

V. Phone/Fax

Practice location:
  • Phone: 605-352-8691
  • Fax:
Mailing address:
  • Phone: 605-868-0636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP002841
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: