Basic Information
| Provider Information | |||||||||
| NPI: | 1285659714 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERDTS | ||||||||
| FirstName: | CORAL | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 UTAH ST | ||||||||
| Address2: | |||||||||
| City: | HIAWATHA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 664342314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7857422131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 12-0311 | KS | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 114052 | 01 | KS | BLUE CROSS OF KS | OTHER | 25014 | 01 | NE | BLUE CROSS | OTHER | 100369010A | 05 | KS | MEDICAID |