Provider Demographics
NPI:1306149539
Name:EISENMENGER FUENTES, KATHRYN SUSAN (PA)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:SUSAN
Last Name:EISENMENGER FUENTES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:SUSAN
Other - Last Name:EISENMENGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2854 HIGHWAY 55
Mailing Address - Street 2:SUITE 130
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2156
Mailing Address - Country:US
Mailing Address - Phone:651-842-3320
Mailing Address - Fax:651-224-5273
Practice Address - Street 1:2854 HIGHWAY 55
Practice Address - Street 2:SUITE 130
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-2156
Practice Address - Country:US
Practice Address - Phone:651-842-3320
Practice Address - Fax:651-224-5273
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant