Provider Demographics
NPI:1669840757
Name:KIBERENGE, TASHA (PA)
Entity Type:Individual
Prefix:
First Name:TASHA
Middle Name:
Last Name:KIBERENGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TASHA
Other - Middle Name:
Other - Last Name:KELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3244 HUMBOLDT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-3328
Mailing Address - Country:US
Mailing Address - Phone:612-839-2955
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-4800
Practice Address - Country:US
Practice Address - Phone:612-672-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12085363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical