Provider Demographics
NPI:1417020793
Name:MATSON, KRISTINE G (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:G
Last Name:MATSON
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 1:400 E THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 MAPLE LN STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:WI
Practice Address - Zip Code:54806-3610
Practice Address - Country:US
Practice Address - Phone:715-685-7500
Practice Address - Fax:715-685-7048
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN30822208000000X
WI63296-202083A0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN381588900Medicaid
MN381588900Medicaid
H04740Medicare UPIN