Provider Demographics
NPI:1588676209
Name:CLUSIAU, KATHRYN J (PA)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:J
Last Name:CLUSIAU
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3605 MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2935
Mailing Address - Country:US
Mailing Address - Phone:218-362-6975
Mailing Address - Fax:218-362-6989
Practice Address - Street 1:3605 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2935
Practice Address - Country:US
Practice Address - Phone:218-362-6975
Practice Address - Fax:218-362-6989
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN751170100Medicaid
MN82G70CLOtherBCBS
MN751170100Medicaid