MEDICARE: PEDIATRIC AND YOUNG ADULT CARE

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	208000000X	Pediatrics Physician	30822	MN

General Provider Information

NPI Number	:	1740396910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC AND YOUNG ADULT CARE

Provider Business Mailing Address
First Line	:	706 SOUTH DIVISION ST
Second Line	:
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-2427
Country	:	US
Telephone Number	:	507-645-9534
Fax Number	:	507-645-8307

Provider Business Practice Location Address
First Line	:	706 SOUTH DIVISION ST
Second Line	:
City	:	NORTHFIELD
State	:	MN
Zip	:	55057-2427
Country	:	US
Telephone Number	:	507-645-9534
Fax Number	:	507-645-8307

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KRISTINE GAYLE MATSON
Credential	:	MD
Telephone Number	:	507-645-9543

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	08/22/2020

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