Provider Demographics
NPI:1225064868
Name:MOTSCHENBACHER, KURTIS K (PA-C)
Entity Type:Individual
Prefix:
First Name:KURTIS
Middle Name:K
Last Name:MOTSCHENBACHER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-8000
Mailing Address - Fax:701-364-8078
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0474363A00000X
MN9529363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN602607900Medicaid
MN602607900Medicaid
P15201Medicare UPIN
P15201Medicare UPIN