Provider Demographics
NPI:1316976236
Name:MELLGREN, KRISTIN K (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:K
Last Name:MELLGREN
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 1:161 19TH ST S STE 106
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-2555
Mailing Address - Country:US
Mailing Address - Phone:320-252-3376
Mailing Address - Fax:218-898-7597
Practice Address - Street 1:161 19TH ST S STE 106
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-2555
Practice Address - Country:US
Practice Address - Phone:320-252-3376
Practice Address - Fax:218-898-7597
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN970001852Medicaid
MN970003697Medicare PIN
MN970001852Medicaid