Provider Demographics
NPI:1649553397
Name:KAINZ, JESSICA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:KAINZ
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 1:710 COMMERCE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4925
Mailing Address - Country:US
Mailing Address - Phone:651-968-5042
Mailing Address - Fax:651-968-5904
Practice Address - Street 1:280 SMITH AVE N STE 500
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2463
Practice Address - Country:US
Practice Address - Phone:651-968-5200
Practice Address - Fax:651-968-5903
Is Sole Proprietor?:No
Enumeration Date:2011-09-20
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2796-023363A00000X
MN11715363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400189969Medicare PIN
WI61085OtherDEAN HEALTH INSURANCE
WI741501871Medicare PIN