Provider Demographics
NPI:1417033507
Name:LESETMOE, KAREN J (PA)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:J
Last Name:LESETMOE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16149 N TRINITY POINT RD SE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:MN
Mailing Address - Zip Code:56736-9493
Mailing Address - Country:US
Mailing Address - Phone:218-687-4144
Mailing Address - Fax:
Practice Address - Street 1:323 S MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1601
Practice Address - Country:US
Practice Address - Phone:800-746-6551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9483363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P31518Medicare UPIN