Provider Demographics
NPI:1417022690
Name:CHURCH, CHRISTOPHER J (PA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:J
Last Name:CHURCH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 STATE AVE
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-6339
Mailing Address - Country:US
Mailing Address - Phone:507-334-8333
Mailing Address - Fax:
Practice Address - Street 1:200 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6339
Practice Address - Country:US
Practice Address - Phone:507-334-8333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP00395174OtherRAILROAD MEDICARE
MN362495000Medicaid
Q75859Medicare UPIN
MN362495000Medicaid