Basic Information
| Provider Information | |||||||||
| NPI: | 1104868231 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRESCOTT | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 12TH ST | ||||||||
| Address2: | |||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8659857258 | ||||||||
| FaxNumber: | 8659857077 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 12TH STREET EXT | ||||||||
| Address2: | PRINCETON COMMUNITY HOSPITAL | ||||||||
| City: | PRINCETON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247402352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044877275 | ||||||||
| FaxNumber: | 3044877153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 10/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 934 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00241089 | 01 | WV | MEDICARE RAILROAD | OTHER | 001902890 | 01 | WV | BLUE CROSS | OTHER |