Provider Demographics
NPI:1760839104
Name:TIMSHINA, INNA
Entity Type:Individual
Prefix:
First Name:INNA
Middle Name:
Last Name:TIMSHINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15704 90TH ST NE
Mailing Address - Street 2:#100
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55330
Mailing Address - Country:US
Mailing Address - Phone:763-241-1090
Mailing Address - Fax:
Practice Address - Street 1:15704 90TH ST NE
Practice Address - Street 2:#100
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330
Practice Address - Country:US
Practice Address - Phone:763-241-1090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3439152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist