Provider Demographics
NPI:1801865084
Name:KITTLESON, TROY PATRICK (GNP)
Entity Type:Individual
Prefix:
First Name:TROY
Middle Name:PATRICK
Last Name:KITTLESON
Suffix:
Gender:M
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10725 AQUILA AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55438-2226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3400 W 66TH ST
Practice Address - Street 2:#290
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55435-2111
Practice Address - Country:US
Practice Address - Phone:952-836-3637
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1394980363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP75090Medicare UPIN