Provider Demographics
NPI:1497019517
Name:OESTREICH, KENDRA NOELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:NOELLE
Last Name:OESTREICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15075 CIMARRON AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-1635
Mailing Address - Country:US
Mailing Address - Phone:651-322-8800
Mailing Address - Fax:
Practice Address - Street 1:15075 CIMARRON AVE
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-1635
Practice Address - Country:US
Practice Address - Phone:651-322-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-03
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11823363A00000X
CO3415363A00000X
MTMED-PAC-LIC-901911363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO16128869Medicaid