Provider Demographics
NPI:1730298910
Name:SHAFFER, KRISTINA KELLY (MD)
Entity Type:Individual
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First Name:KRISTINA
Middle Name:KELLY
Last Name:SHAFFER
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Gender:F
Credentials:MD
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Mailing Address - Street 1:60 PLATO BLVD E
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1827
Mailing Address - Country:US
Mailing Address - Phone:651-209-1600
Mailing Address - Fax:651-291-9169
Practice Address - Street 1:1215 TOWN CENTRE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1033
Practice Address - Country:US
Practice Address - Phone:651-251-3300
Practice Address - Fax:651-255-3450
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2013-01-28
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Provider Licenses
StateLicense IDTaxonomies
MN43145207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN190170200Medicaid
MN190170200Medicaid