Basic Information
| Provider Information | |||||||||
| NPI: | 1548286248 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANGBORN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 W CEDAR ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325024910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004447009 | ||||||||
| FaxNumber: | 8185872493 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E WASHINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074648511 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G39084 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G390840 | 01 | CA | BLUE SHIELD | OTHER | 00G390840 | 05 | CA | MEDICAID |