Provider Demographics
NPI:1033695960
Name:LEDERER, TIMOTHY JON
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JON
Last Name:LEDERER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WALTER WARD BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-1286
Mailing Address - Country:US
Mailing Address - Phone:410-777-8971
Mailing Address - Fax:
Practice Address - Street 1:100 WALTER WARD BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-1286
Practice Address - Country:US
Practice Address - Phone:410-777-8971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDF06180825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily