MEDICARE: MR. JACOB GREGORY GUTH P.A.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	393	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1047498	OTHER	MN	PREFERRED ONE
2	135584	OTHER	MN	UCARE
3	527G9GU	OTHER	MN	BLUE CROSS & BLUE SHIELD
4	HP65749	OTHER	MN	HEALTH PARTNERS
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	2443375	OTHER	MN	AMERICAS PPO
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
8	0124329	OTHER	MN	MEDICA

General Provider Information

NPI Number	:	1134169774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JACOB GREGORY GUTH P.A.C

Provider Business Mailing Address
First Line	:	1950 NORTHWESTERN AVE S STE 102
Second Line	:
City	:	STILLWATER
State	:	MN
Zip	:	55082-7615
Country	:	US
Telephone Number	:	651-430-3800
Fax Number	:	651-430-3827

Provider Business Practice Location Address
First Line	:	1835 COUNTY ROAD C WEST
Second Line	:	SUITE 150
City	:	STILLWATER
State	:	MN
Zip	:	55082-5078
Country	:	US
Telephone Number	:	651-259-4501
Fax Number	:	651-430-1447

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	03/11/2021

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Directions to “ MR. JACOB GREGORY GUTH P.A.C” Practice Location

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