Basic Information
Provider Information | |||||||||
NPI: | 1518148873 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PACE | ||||||||
FirstName: | TIMOTHY | ||||||||
MiddleName: | WAYNE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3342 BOPEG RD | ||||||||
Address2: |   | ||||||||
City: | CANTONMENT | ||||||||
State: | FL | ||||||||
PostalCode: | 325337014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8505720296 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 24 MILES CENTER WAY | ||||||||
Address2: |   | ||||||||
City: | DAMARISCOTTA | ||||||||
State: | ME | ||||||||
PostalCode: | 045434067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2075631040 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2007 | ||||||||
LastUpdateDate: | 07/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1939 | NE | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA9104343 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AS0400X | PA644 | AL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA9104343 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA1385 | ME | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 102978408 | 01 | AL | MEDICARE PTAN | OTHER | 262936800 | 05 | FL |   | MEDICAID |