Provider Demographics
NPI:1184870255
Name:KIRKSSON, ERIC EVAN (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:EVAN
Last Name:KIRKSSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 PAYNE AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55130-3433
Mailing Address - Country:US
Mailing Address - Phone:651-371-4880
Mailing Address - Fax:651-371-4881
Practice Address - Street 1:1321 PAYNE AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-3433
Practice Address - Country:US
Practice Address - Phone:651-371-4880
Practice Address - Fax:651-371-4881
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI56002208100000X
MN51158208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN250000801Medicare PIN
WIAPPRMedicaid