Provider Demographics
NPI:1649348426
Name:MONTAG, TIMOTHY JOSEPH (PA-C)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:MONTAG
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Gender:M
Credentials:PA-C
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Mailing Address - Street 1:9645 GROVE CIRCLE NORTH
Mailing Address - Street 2:STE 200
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4466
Mailing Address - Country:US
Mailing Address - Phone:763-201-8191
Mailing Address - Fax:763-201-8192
Practice Address - Street 1:9645 GROVE CIRCLE NORTH
Practice Address - Street 2:STE 200
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-4466
Practice Address - Country:US
Practice Address - Phone:763-201-8191
Practice Address - Fax:763-201-8192
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2018-04-30
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Provider Licenses
StateLicense IDTaxonomies
MN1735363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN058133000Medicaid
045N0MOOtherBLUE CROSS BLUE SHIELD
V10774Medicare UPIN
MN058133000Medicaid