Basic Information
Provider Information | |||||||||
NPI: | 1760457451 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JEFFERSON | ||||||||
FirstName: | KARI | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TOMAN | ||||||||
OtherFirstName: | KARI | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 200 1ST ST SW | ||||||||
Address2: |   | ||||||||
City: | ROCHESTER | ||||||||
State: | MN | ||||||||
PostalCode: | 559050001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6087850940 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 800 WEST AVENUE SOUTH | ||||||||
Address2: |   | ||||||||
City: | LA CROSSE | ||||||||
State: | WI | ||||||||
PostalCode: | 54601 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083929876 | ||||||||
FaxNumber: | 6083923955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/17/2006 | ||||||||
LastUpdateDate: | 08/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 2557 | WI | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | 085003483 | IL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 2557 | WI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.