Provider Demographics
NPI:1235623455
Name:FORTIER, JOSEPH MATHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MATHEW
Last Name:FORTIER
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 1:11224 LAKEVIEW HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-5363
Mailing Address - Country:US
Mailing Address - Phone:320-469-2493
Mailing Address - Fax:
Practice Address - Street 1:1901 CONNECTICUT AVE S
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377
Practice Address - Country:US
Practice Address - Phone:320-259-4100
Practice Address - Fax:320-257-5523
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-20
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4375-23363A00000X
MN12790363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant