Provider Demographics
NPI:1134169774
Name:GUTH, JACOB GREGORY (PAC)
Entity type:Individual
Prefix:MR
First Name:JACOB
Middle Name:GREGORY
Last Name:GUTH
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 NORTHWESTERN AVE S STE 102
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-7615
Mailing Address - Country:US
Mailing Address - Phone:651-430-3800
Mailing Address - Fax:651-430-3827
Practice Address - Street 1:1835 COUNTY ROAD C WEST
Practice Address - Street 2:SUITE 150
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-5078
Practice Address - Country:US
Practice Address - Phone:651-259-4501
Practice Address - Fax:651-430-1447
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN393363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1047498OtherPREFERRED ONE
MN135584OtherUCARE
MN527G9GUOtherBLUE CROSS & BLUE SHIELD
MNHP65749OtherHEALTH PARTNERS
MN747410500Medicaid
MN2443375OtherAMERICAS PPO
WI42886700Medicaid
MN0124329OtherMEDICA
WI42886700Medicaid
WI491750010Medicare PIN
MN2443375OtherAMERICAS PPO
MN970002605Medicare PIN