Provider Demographics
NPI:1003844200
Name:WOLF, TIMOTHY J (CRNA08/)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:WOLF
Suffix:
Gender:M
Credentials:CRNA08/
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1412
Mailing Address - Country:US
Mailing Address - Phone:909-946-5752
Mailing Address - Fax:909-985-3858
Practice Address - Street 1:725 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2614
Practice Address - Country:US
Practice Address - Phone:909-946-5752
Practice Address - Fax:909-985-3858
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA061367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANA0000610OtherBLUE SHIELD
CARN1879391Medicaid
CAZZZ15368ZMedicare ID - Type Unspecified
CANA0000610OtherBLUE SHIELD