Basic Information
| Provider Information | |||||||||
| NPI: | 1467589051 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 BRADBURY DR SE STE 2222 | ||||||||
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| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052723200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 BROADMOOR BLVD NE | ||||||||
| Address2: | |||||||||
| City: | RIO RANCHO | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871442100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059947422 | ||||||||
| FaxNumber: | 5059947394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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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 | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA2016-0025 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.