Provider Demographics
NPI:1063496222
Name:ANDERSON, TIMOTHY (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:954 LAKE BALDWIN LN
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6651
Mailing Address - Country:US
Mailing Address - Phone:407-478-9797
Mailing Address - Fax:407-478-9798
Practice Address - Street 1:954 LAKE BALDWIN LN
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32814-6651
Practice Address - Country:US
Practice Address - Phone:407-478-9797
Practice Address - Fax:407-478-9798
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03747363A00000X
FLPA 908641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P98719Medicare UPIN
TX8D9391Medicare PIN