Basic Information
| Provider Information | |||||||||
| NPI: | 1194709881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUCHEK | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 504 PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934546917 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393474 | ||||||||
| FaxNumber: | 8053463548 | ||||||||
| Practice Location | |||||||||
| Address1: | 715 TANK FARM RD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934017068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055435577 | ||||||||
| FaxNumber: | 8055953231 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 10/27/2016 | ||||||||
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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 | PA 13772 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MS1155628 | 01 | CA | DEA REGISTRATION # | OTHER |