Provider Demographics
NPI:1407109275
Name:MIX, KASIE JEAN (OD, MS)
Entity Type:Individual
Prefix:
First Name:KASIE
Middle Name:JEAN
Last Name:MIX
Suffix:
Gender:F
Credentials:OD, MS
Other - Prefix:
Other - First Name:KASIE
Other - Middle Name:JEAN
Other - Last Name:RUST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1455 SAINT FRANCIS AVE
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3374
Practice Address - Country:US
Practice Address - Phone:952-993-3150
Practice Address - Fax:952-993-7835
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3429152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management