Provider Demographics
NPI:1831159680
Name:BORESPUPP, KRISTINA M (OD)
Entity type:Individual
Prefix:DR
First Name:KRISTINA
Middle Name:M
Last Name:BORESPUPP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3715 MARSH PT W
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MN
Mailing Address - Zip Code:55359-9820
Mailing Address - Country:US
Mailing Address - Phone:763-479-3794
Mailing Address - Fax:
Practice Address - Street 1:4455 HIGHWAY 169 N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2897
Practice Address - Country:US
Practice Address - Phone:763-551-0529
Practice Address - Fax:763-559-6010
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2479152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU54141Medicare UPIN