MEDICARE: KRISTIN K MELLGREN 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	9855	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316976236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN K MELLGREN PA-C

Provider Business Mailing Address
First Line	:	161 19TH ST S STE 106
Second Line	:
City	:	SARTELL
State	:	MN
Zip	:	56377-2555
Country	:	US
Telephone Number	:	320-252-3376
Fax Number	:	320-288-2701

Provider Business Practice Location Address
First Line	:	161 19TH ST S STE 106
Second Line	:
City	:	SARTELL
State	:	MN
Zip	:	56377-2555
Country	:	US
Telephone Number	:	320-252-3376
Fax Number	:	320-288-2701

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

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	09/05/2025

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