Provider Demographics
NPI:1265898522
Name:BALLWEG, KRISTINE KAY
Entity type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:KAY
Last Name:BALLWEG
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KRISTINE
Other - Middle Name:KAY
Other - Last Name:SCHUETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 207
Mailing Address - Street 2:505 39TH AVE
Mailing Address - City:AMANA
Mailing Address - State:IA
Mailing Address - Zip Code:52203
Mailing Address - Country:US
Mailing Address - Phone:319-622-3231
Mailing Address - Fax:319-622-3077
Practice Address - Street 1:505 39TH AVE
Practice Address - Street 2:
Practice Address - City:AMANA
Practice Address - State:IA
Practice Address - Zip Code:52203
Practice Address - Country:US
Practice Address - Phone:319-622-3231
Practice Address - Fax:319-622-3077
Is Sole Proprietor?:No
Enumeration Date:2016-01-01
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI74950005Medicare UPIN