Provider Demographics
NPI:1245202399
Name:TIMM, MICHAEL R (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:TIMM
Suffix:
Gender:M
Credentials:PAC
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Other - Credentials:
Mailing Address - Street 1:8100 34TH AVE S
Mailing Address - Street 2:MAIL STOP 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-1672
Mailing Address - Country:US
Mailing Address - Phone:952-883-5463
Mailing Address - Fax:952-883-5395
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:MC 11503J
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-5701
Practice Address - Fax:651-254-1519
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2015-03-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN9878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN660159600Medicaid
970002257Medicare ID - Type Unspecified
MN660159600Medicaid