Provider Demographics
NPI:1548945397
Name:FRESONKE, TIMOTHY RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:FRESONKE
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 1:1000 CONEY ST W
Mailing Address - Street 2:
Mailing Address - City:PERHAM
Mailing Address - State:MN
Mailing Address - Zip Code:56573-2102
Mailing Address - Country:US
Mailing Address - Phone:218-347-1400
Mailing Address - Fax:
Practice Address - Street 1:1000 CONEY ST W
Practice Address - Street 2:
Practice Address - City:PERHAM
Practice Address - State:MN
Practice Address - Zip Code:56573-2102
Practice Address - Country:US
Practice Address - Phone:218-347-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-20
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant