Provider Demographics
NPI:1821657065
Name:GRETSCH, KAITLYN MAE
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:MAE
Last Name:GRETSCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5045 KAGAN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-3521
Mailing Address - Country:US
Mailing Address - Phone:320-219-8566
Mailing Address - Fax:
Practice Address - Street 1:201 E NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5714
Practice Address - Country:US
Practice Address - Phone:952-892-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant