Provider Demographics
NPI:1164651824
Name:JOHNSON, KRISTINE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTINE
Other - Middle Name:ANN
Other - Last Name:KUNNARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2025 SLOAN PL STE 35
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55117-2092
Mailing Address - Country:US
Mailing Address - Phone:651-772-1572
Mailing Address - Fax:651-772-1889
Practice Address - Street 1:2601 CENTENNIAL DR STE 100
Practice Address - Street 2:
Practice Address - City:NORTH ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55109-3087
Practice Address - Country:US
Practice Address - Phone:651-777-7414
Practice Address - Fax:651-748-5839
Is Sole Proprietor?:No
Enumeration Date:2009-07-02
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10583363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant