Provider Demographics
NPI:1386377901
Name:RUSTAD, KELSIE JEAN (PA-C)
Entity type:Individual
Prefix:
First Name:KELSIE
Middle Name:JEAN
Last Name:RUSTAD
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 1:600 PETERSON PKWY
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:MN
Mailing Address - Zip Code:56273-7823
Mailing Address - Country:US
Mailing Address - Phone:320-354-2222
Mailing Address - Fax:
Practice Address - Street 1:600 PETERSON PKWY
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:MN
Practice Address - Zip Code:56273-7823
Practice Address - Country:US
Practice Address - Phone:320-444-8287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty