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NPI Code Detail

MEDICARE: MRS. ALLYSSA MAE KITTOCK PA

MEDICARE: MRS. ALLYSSA MAE KITTOCK PA
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
1363A00000XPhysician Assistant

General Provider Information

NPI Number : 1902203045
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. ALLYSSA MAE KITTOCK PA
Provider Business Mailing Address
First Line : 8170 33RD AVE S # MS 21110Q
Second Line :
City : BLOOMINGTON
State : MN
Zip : 55425-4516
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 5400 EXCELSIOR BLVD
Second Line :
City : ST LOUIS PARK
State : MN
Zip : 55416-2913
Country : US
Telephone Number : 952-993-1000
Fax Number : 952-993-1160
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/03/2014
Last Update Date : 06/29/2022

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