Healthcare Provider Details

I. General information

NPI: 1518021948
Provider Name (Legal Business Name): TIMOTHY JOSEPH PAMPUSCH PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 10/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 FULTON ST SE
MINNEAPOLIS MN
55455-4800
US

IV. Provider business mailing address

5803 NEAL AVE N
OAK PARK HEIGHTS MN
55082-2177
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-7422
  • Fax:
Mailing address:
  • Phone: 651-439-8807
  • Fax: 651-439-0232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3505-23
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number536
License Number StateAK
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10884
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: