Provider Demographics
NPI:1356502769
Name:KIESOW, NICOLE MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:MARIE
Last Name:KIESOW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:900 HILLIGOSS BLVD SE
Mailing Address - Street 2:
Mailing Address - City:FOSSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56542
Mailing Address - Country:US
Mailing Address - Phone:218-435-1212
Mailing Address - Fax:218-435-2550
Practice Address - Street 1:900 HILLIGOSS BLVD SE
Practice Address - Street 2:
Practice Address - City:FOSSTON
Practice Address - State:MN
Practice Address - Zip Code:56542-1542
Practice Address - Country:US
Practice Address - Phone:218-435-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2018-04-16
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant