Basic Information
| Provider Information | |||||||||
| NPI: | 1750314225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHTY | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2420 HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | KINGSBURG | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936132733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165851850 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1141 ROSE AVENUE | ||||||||
| Address2: | |||||||||
| City: | SELMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 936622640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598911000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 09/10/2019 | ||||||||
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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 | 163W00000X | 145155 | MO | N | Nursing Service Providers | Registered Nurse | 367500000X | 145155 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | NA3913 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 200305650A | 05 | KS | MEDICAID | 919046300 | 05 | MO | MEDICAID |