Provider Demographics
NPI:1508472473
Name:HEDSTROM, CHRISTINE GENEVIEVE
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:GENEVIEVE
Last Name:HEDSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 356
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:ND
Mailing Address - Zip Code:58367-0356
Mailing Address - Country:US
Mailing Address - Phone:763-228-9496
Mailing Address - Fax:
Practice Address - Street 1:401 2ND AVE
Practice Address - Street 2:
Practice Address - City:ROLETTE
Practice Address - State:ND
Practice Address - Zip Code:58366
Practice Address - Country:US
Practice Address - Phone:701-246-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0854363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant