Provider Demographics
NPI:1306005574
Name:WEINGARTZ, TIFFANI I (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANI
Middle Name:I
Last Name:WEINGARTZ
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIFFANI
Other - Middle Name:I
Other - Last Name:FLATEGRAFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 1309
Mailing Address - Street 2:8170 33RD AVE S.
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-254-2300
Mailing Address - Fax:651-254-2301
Practice Address - Street 1:640 JACKSON STREET
Practice Address - Street 2:MAIL STOP 11302C
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-2300
Practice Address - Fax:651-254-2301
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10423363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MN970003521Medicare PIN