Provider Demographics
NPI:1396110516
Name:RELLER, KARA KRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:KARA
Middle Name:KRISTINE
Last Name:RELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KARA
Other - Middle Name:KRISTINE
Other - Last Name:MCDERMOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1515 W 5TH ST
Mailing Address - Street 2:APT 203
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-2323
Mailing Address - Country:US
Mailing Address - Phone:972-523-1867
Mailing Address - Fax:
Practice Address - Street 1:420 E SARNIA ST
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987-6365
Practice Address - Country:US
Practice Address - Phone:507-474-7830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2381363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical