Basic Information
Provider Information | |||||||||
NPI: | 1316185499 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRINKER | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | MARTIN | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2960 TONGASS AVENUE | ||||||||
Address2: |   | ||||||||
City: | KETCHIKAN | ||||||||
State: | AK | ||||||||
PostalCode: | 999015742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072284900 | ||||||||
FaxNumber: | 8008523264 | ||||||||
Practice Location | |||||||||
Address1: | 2960 TONGASS AVENUE | ||||||||
Address2: |   | ||||||||
City: | KETCHIKAN | ||||||||
State: | AK | ||||||||
PostalCode: | 999015742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072284900 | ||||||||
FaxNumber: | 8008523264 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2009 | ||||||||
LastUpdateDate: | 08/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | BR96799 | AS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1574400 | 05 | AK |   | MEDICAID |