Provider Demographics
NPI:1013424191
Name:LA GASSE, TIMOTHY ROBERT (NP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ROBERT
Last Name:LA GASSE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:WALLOON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49796-0185
Mailing Address - Country:US
Mailing Address - Phone:231-535-6067
Mailing Address - Fax:
Practice Address - Street 1:401 CONNABLE AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-487-4520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704249602363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty