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General NPI Number Information
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NPI Number | 1730072901
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Entity Type | Individual
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Provider Name | MICHAEL ANTHONY KALLSEN FNP-BC
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Gender | Male
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Dates
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Enumeration Date | 05/29/2025
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Last Update Date | 05/29/2025
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Provider Practice Location Address
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Address Line | 191 AZ-264
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City | GANADO
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State | AZ
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Zip | 86505
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Country | US
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Telephone | 509-703-0262
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Fax |
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Provider Business Mailing Address
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Address Line | 4077 CAMBRIDGE CIR
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City | RIGBY
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State | ID
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Zip | 83442-5299
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 3971257
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License Number State | ID
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