1275638603 NPI number — KARA KOLQUIST STOKKE P.T.

Table of content: KARA KOLQUIST STOKKE P.T. (NPI 1275638603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275638603 NPI number — KARA KOLQUIST STOKKE P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STOKKE
Provider First Name:
KARA
Provider Middle Name:
KOLQUIST
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KOLQUIST
Provider Other First Name:
KARA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275638603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1420 LONDON RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805-2433
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-728-3774
Provider Business Mailing Address Fax Number:
218-728-3640

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1420 LONDON RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55805-2433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-728-3774
Provider Business Practice Location Address Fax Number:
218-728-3640
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  7699 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 36102400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 093H7KO . This is a "BCBSMN INDIVIDUAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 6406275 . This is a "MEDICA INDIVIDUAL" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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