Basic Information
| Provider Information | |||||||||
| NPI: | 1831271840 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOHAN | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 E PIMA STREET | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857125601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203822819 | ||||||||
| FaxNumber: | 5203822832 | ||||||||
| Practice Location | |||||||||
| Address1: | 5700 E PIMA STREET | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857122805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5203241922 | ||||||||
| FaxNumber: | 5203241088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 363L00000X | AP1294 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 569212-02 | 05 | AZ | MEDICAID | 569212 | 01 | AZ | AHCCCS | OTHER |