Provider Demographics
NPI:1649026139
Name:SEDLAK, TIMOTHY (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SEDLAK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:SEDLAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1130
Mailing Address - Street 2:
Mailing Address - City:MINOCQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54548-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:353 FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-7375
Practice Address - Country:US
Practice Address - Phone:605-755-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant