1306149539 NPI number — MS. KATHRYN SUSAN EISENMENGER FUENTES PA

Table of content: MS. KATHRYN SUSAN EISENMENGER FUENTES PA (NPI 1306149539)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306149539 NPI number — MS. KATHRYN SUSAN EISENMENGER FUENTES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EISENMENGER FUENTES
Provider First Name:
KATHRYN
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EISENMENGER
Provider Other First Name:
KATHRYN
Provider Other Middle Name:
SUSAN
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:
1306149539
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2854 HIGHWAY 55
Provider Second Line Business Mailing Address:
SUITE 130
Provider Business Mailing Address City Name:
EAGAN
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55121-2156
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-842-3320
Provider Business Mailing Address Fax Number:
651-224-5273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2854 HIGHWAY 55
Provider Second Line Business Practice Location Address:
SUITE 130
Provider Business Practice Location Address City Name:
EAGAN
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55121-2156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-842-3320
Provider Business Practice Location Address Fax Number:
651-224-5273
Provider Enumeration Date:
12/09/2010

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: 363A00000X , with the licence number:  1514 , 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)





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