Provider Demographics
NPI:1063508414
Name:TIMMONS, WENDY ROBERTA (PAC)
Entity Type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:ROBERTA
Last Name:TIMMONS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:WENDY
Other - Middle Name:ROBERTA
Other - Last Name:OOSTING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4480 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3674
Mailing Address - Country:US
Mailing Address - Phone:651-484-2724
Mailing Address - Fax:651-484-2723
Practice Address - Street 1:4480 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55127-3674
Practice Address - Country:US
Practice Address - Phone:651-484-2724
Practice Address - Fax:651-484-2723
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10167207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology