Provider Demographics
NPI:1083608020
Name:KATSARES, KIESHA MARIE (ARNP)
Entity Type:Individual
Prefix:
First Name:KIESHA
Middle Name:MARIE
Last Name:KATSARES
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KIESHA
Other - Middle Name:MARIE
Other - Last Name:RABURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:9900 BREN RD E
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9664
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:813-416-0827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2022-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3088792163W00000X
OH12902163WH0200X, 363LA2200X
FLARNP3088792363LA2200X
CANP95019436363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL307402100Medicaid
FLY081KOtherBCBS
FLY081KOtherBCBS