Provider Demographics
NPI:1184666463
Name:VAN WYK, KRISTIN (PT)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:VAN WYK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7541 9TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6626
Mailing Address - Country:US
Mailing Address - Phone:651-748-4338
Mailing Address - Fax:651-748-2892
Practice Address - Street 1:14000 NICOLLET AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5790
Practice Address - Country:US
Practice Address - Phone:952-892-6777
Practice Address - Fax:952-892-0792
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN992358600Medicaid
MN200K2VAOtherBLUE CROSS MN
MN6401416OtherMEDICA
MNHP35850OtherHEALTHPARTNERS
MN200K2VAOtherBLUE CROSS MN