Provider Demographics
NPI:1952865875
Name:TRAEGER, BRIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:TRAEGER
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 1:6300 WEDGWOOD RD N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-3647
Mailing Address - Country:US
Mailing Address - Phone:763-551-1215
Mailing Address - Fax:
Practice Address - Street 1:6300 WEDGWOOD RD N
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-3647
Practice Address - Country:US
Practice Address - Phone:763-551-1215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant