Basic Information
| Provider Information | |||||||||
| NPI: | 1730643032 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIFFERENT | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847522 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847522 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035315000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2026 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757665822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035865678 | ||||||||
| FaxNumber: | 9035414679 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2019 | ||||||||
| LastUpdateDate: | 05/21/2019 | ||||||||
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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 | 367500000X | AP140173 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 769641 | 01 | TX | MEDICARE | OTHER | 8KP517 | 01 | TX | BCBS | OTHER | 394643601 | 05 | TX | MEDICAID | P02210751 | 01 | TX | MEDICARE RAIL ROAD | OTHER |