Provider Demographics
NPI:1881764876
Name:RISTAU, SHANNON MARIE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:RISTAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SAINT CLAIR AVE
Mailing Address - Street 2:APT #407
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1962
Mailing Address - Country:US
Mailing Address - Phone:651-690-0177
Mailing Address - Fax:
Practice Address - Street 1:2115 SUMMIT AVE
Practice Address - Street 2:LORAS HALL 406
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1048
Practice Address - Country:US
Practice Address - Phone:503-396-2896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program