Provider Demographics
NPI:1710013610
Name:DEJEAN, KIRSTEN R (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:R
Last Name:DEJEAN
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 1:2707 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-5111
Mailing Address - Country:US
Mailing Address - Phone:605-665-1267
Mailing Address - Fax:
Practice Address - Street 1:3515 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-7600
Practice Address - Country:US
Practice Address - Phone:605-668-3100
Practice Address - Fax:605-668-3460
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDR82575Medicare UPIN
SD3790Medicare PIN