Provider Demographics
NPI:1104981778
Name:STRUCK, KJERSTEN WING (NP)
Entity type:Individual
Prefix:
First Name:KJERSTEN
Middle Name:WING
Last Name:STRUCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KJERSTEN
Other - Middle Name:JONNA
Other - Last Name:WING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2829 UNIVERSITY AVE SE STE 730
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3279
Mailing Address - Country:US
Mailing Address - Phone:612-439-1868
Mailing Address - Fax:
Practice Address - Street 1:2855 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2649
Practice Address - Country:US
Practice Address - Phone:763-577-7160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR140963-6363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN882949700Medicaid