Provider Demographics
NPI:1043281397
Name:YARTZ, TREVOR (PA)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:YARTZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 5TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-2914
Mailing Address - Country:US
Mailing Address - Phone:218-751-4144
Mailing Address - Fax:218-751-3545
Practice Address - Street 1:619 5TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-2914
Practice Address - Country:US
Practice Address - Phone:218-751-4144
Practice Address - Fax:218-751-3545
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN488963100Medicaid