Provider Demographics
NPI:1083397947
Name:LUND, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:LUND
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 SMITH AVE N STE 210
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2518
Mailing Address - Country:US
Mailing Address - Phone:651-241-4622
Mailing Address - Fax:651-241-7100
Practice Address - Street 1:255 SMITH AVE N STE 210
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2518
Practice Address - Country:US
Practice Address - Phone:651-241-4622
Practice Address - Fax:651-241-7100
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-08
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN14776363A00000X
MN363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical