MEDICARE: CHRISTA NICOLE STOUT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	3448	WI
2	363A00000X	Physician Assistant	11731	MN

General Provider Information

NPI Number	:	1073919205
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTA NICOLE STOUT PA-C

Provider Business Mailing Address
First Line	:	2720 FAIRVIEW AVE N STE 100
Second Line	:
City	:	ROSEVILLE
State	:	MN
Zip	:	55113-1306
Country	:	US
Telephone Number	:	651-241-5290
Fax Number	:

Provider Business Practice Location Address
First Line	:	2720 FAIRVIEW AVE N STE 100
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55113-1306
Country	:	US
Telephone Number	:	651-241-5290
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/17/2014
Last Update Date	:	03/28/2022

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Directions to “ CHRISTA NICOLE STOUT PA-C” Practice Location

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