Basic Information
Provider Information | |||||||||
NPI: | 1821483967 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRISTAN | ||||||||
FirstName: | MEGAN | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JANNI | ||||||||
OtherFirstName: | MEGAN | ||||||||
OtherMiddleName: | MARIE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3800 RESERVOIR RD NW | ||||||||
Address2: | DEPARTMENT OF MEDICINE | ||||||||
City: | WASHINGTON | ||||||||
State: | DC | ||||||||
PostalCode: | 200072113 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2024448168 | ||||||||
FaxNumber: | 8773031460 | ||||||||
Practice Location | |||||||||
Address1: | 6525 FRANCE AVE S STE 200 | ||||||||
Address2: |   | ||||||||
City: | EDINA | ||||||||
State: | MN | ||||||||
PostalCode: | 554352176 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9528488890 | ||||||||
FaxNumber: | 9528488892 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/06/2015 | ||||||||
LastUpdateDate: | 09/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101262127 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.