Provider Demographics
NPI:1922407030
Name:STOMPRO, KRISTINE LEA (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:LEA
Last Name:STOMPRO
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 1:400 EAST THIRD STREET
Mailing Address - Street 2:ESSENTIA HEALTH DULUTH CLINIC MCL2CRED
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-1183
Mailing Address - Fax:
Practice Address - Street 1:1027 WASHINGTON AVENUE
Practice Address - Street 2:EH ST MARY'S-DETROIT LAKES CLINIC URGENT CARE
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-4402255A2300X
MN12586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer