Provider Demographics
NPI:1972072700
Name:BARTENBERGER, KEVIN TODD (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:TODD
Last Name:BARTENBERGER
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 1:3113 LAKE VISTA DR NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7407
Mailing Address - Country:US
Mailing Address - Phone:513-515-1234
Mailing Address - Fax:
Practice Address - Street 1:1000 1ST DR NW
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:MN
Practice Address - Zip Code:55912-2941
Practice Address - Country:US
Practice Address - Phone:507-433-7351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-22
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant