Provider Demographics
NPI:1083486625
Name:RACE, TIMOTHY MATTHEW (MSN, CRNP, PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MATTHEW
Last Name:RACE
Suffix:
Gender:M
Credentials:MSN, CRNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 DAVENPORT ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:PA
Mailing Address - Zip Code:18651-1604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:142 DAVENPORT ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:PA
Practice Address - Zip Code:18651-1604
Practice Address - Country:US
Practice Address - Phone:570-899-1871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-26
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP028392363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health