Provider Demographics
NPI:1770822330
Name:BOHLIG, KRISTI MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:MICHELLE
Last Name:BOHLIG
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 1:1990 CONNECTICUT AVE S STE 100
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2554
Mailing Address - Country:US
Mailing Address - Phone:202-575-5953
Mailing Address - Fax:320-257-5596
Practice Address - Street 1:1990 CONNECTICUT AVE S STE 100
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2554
Practice Address - Country:US
Practice Address - Phone:202-575-5953
Practice Address - Fax:320-257-5596
Is Sole Proprietor?:No
Enumeration Date:2013-02-01
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND923133V00000X
MN13049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND923OtherND LICENSURE
MN13049OtherMN LICENSE