Provider Demographics
NPI:1073919205
Name:STOUT, CHRISTA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:NICOLE
Last Name:STOUT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 FAIRVIEW AVE N STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1306
Mailing Address - Country:US
Mailing Address - Phone:651-241-5290
Mailing Address - Fax:
Practice Address - Street 1:2720 FAIRVIEW AVE N STE 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55113-1306
Practice Address - Country:US
Practice Address - Phone:651-241-5290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-17
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3448363A00000X
MN11731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant