Basic Information
| Provider Information | |||||||||
| NPI: | 1033160346 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEA | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | JOHN | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602373 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282131500 | ||||||||
| FaxNumber: | 8286516570 | ||||||||
| Practice Location | |||||||||
| Address1: | 1409 ASHEVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | BREVARD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287129524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284358400 | ||||||||
| FaxNumber: | 8284358401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9800693 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | NC6503C | 01 | NC | MEDICARE PTAN | OTHER | NC6503D | 01 | NC | MEDICARE PTAN | OTHER | 2254955B | 01 | NC | MEDICARE PTAN | OTHER | NC6503A | 01 | NC | MEDICARE PTAN | OTHER | NC6503B | 01 | NC | MEDICARE PTAN | OTHER |