Provider Demographics
NPI:1134637986
Name:LICHTENBERG, KRISTY JORDAN (PA)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:JORDAN
Last Name:LICHTENBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVENUE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:225 SMITH AVE N
Practice Address - Street 2:STE 200
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2697
Practice Address - Country:US
Practice Address - Phone:651-241-5111
Practice Address - Fax:651-241-5512
Is Sole Proprietor?:No
Enumeration Date:2018-01-15
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
MN12632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical