Provider Demographics
NPI:1861638306
Name:MENARD, TIMOTHY J (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:MENARD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W COURT ST STE 410
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3675
Mailing Address - Country:US
Mailing Address - Phone:815-802-0731
Mailing Address - Fax:
Practice Address - Street 1:3000 S JUSTICE WAY
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-8449
Practice Address - Country:US
Practice Address - Phone:815-802-0731
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000584363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical