Provider Demographics
NPI:1285635136
Name:STREET, TIMOTHY N (PA C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:N
Last Name:STREET
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 1:1400 29TH ST S
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5353
Mailing Address - Country:US
Mailing Address - Phone:406-454-2171
Mailing Address - Fax:406-771-3021
Practice Address - Street 1:1600 DIVISION RD
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-1921
Practice Address - Country:US
Practice Address - Phone:406-268-1600
Practice Address - Fax:406-771-3549
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT143363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0436800Medicaid
MT000081836Medicare PIN
S54840Medicare UPIN