Basic Information
| Provider Information | |||||||||
| NPI: | 1679058762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ASMUS | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 710 N NILES AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466171924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746471610 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 NAVARRE PL STE 5500 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466011172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5746475300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2018 | ||||||||
| LastUpdateDate: | 11/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 28193580A | IN | N | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 363LF0000X | 71008462A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 261970104 | 01 | IN | MEDICARE PTAN | OTHER | 300020098 | 05 | IN | MEDICAID | 169380084 | 01 | IN | MEDICARE PTAN | OTHER | 247000032 | 01 | IN | MEDICARE PTAN | OTHER |