Provider Demographics
NPI:1457307316
Name:GENDRON, KRISTIN (MD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:GENDRON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2080 WOODWINDS DR STE 120
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-2524
Mailing Address - Country:US
Mailing Address - Phone:651-702-0570
Mailing Address - Fax:651-645-6166
Practice Address - Street 1:2080 WOODWINDS DRIVE #240
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-702-0750
Practice Address - Fax:651-645-6166
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN49403207Y00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN065435000Medicaid