Provider Demographics
NPI: | 1265469647 |
---|---|
Name: | KRIEG, JENNIFER J (PA) |
Entity Type: | Individual |
Prefix: | |
First Name: | JENNIFER |
Middle Name: | J |
Last Name: | KRIEG |
Suffix: | |
Gender: | F |
Credentials: | PA |
Other - Prefix: | |
Other - First Name: | JENNIFER |
Other - Middle Name: | |
Other - Last Name: | HANSEN |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 710 COMMERCE DR STE 200 |
Mailing Address - Street 2: | |
Mailing Address - City: | WOODBURY |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55125-4925 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 17210 KENYON AVE |
Practice Address - Street 2: | |
Practice Address - City: | LAKEVILLE |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55044-6903 |
Practice Address - Country: | US |
Practice Address - Phone: | 651-968-5201 |
Practice Address - Fax: | 651-968-5903 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-28 |
Last Update Date: | 2023-07-13 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 2709 | 363A00000X |
IA | 001726 | 363AS0400X |
MN | 13825 | 363A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | |
No | 363AS0400X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
I18056 | Medicare PIN |