Provider Demographics
NPI:1164718607
Name:DESAUTELS, CHRISTINE NICHOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:NICHOLE
Last Name:DESAUTELS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 EMERSON AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-1232
Mailing Address - Country:US
Mailing Address - Phone:925-708-5325
Mailing Address - Fax:
Practice Address - Street 1:8100 W. 78TH ST. #100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55439-2529
Practice Address - Country:US
Practice Address - Phone:612-262-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN55263207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1164718607Medicare PIN