Provider Demographics
NPI:1093750499
Name:KIRESUK, TERESA (NP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:KIRESUK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 BANDANA BLVD E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5113
Mailing Address - Country:US
Mailing Address - Phone:651-642-2700
Mailing Address - Fax:651-642-9441
Practice Address - Street 1:1021 BANDANA BLVD E
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5113
Practice Address - Country:US
Practice Address - Phone:651-637-2960
Practice Address - Fax:651-637-2961
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1133714363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
R94985Medicare UPIN