Provider Demographics
NPI:1083717029
Name:PRIETO-KOP, TIMOTHY PA (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PA
Last Name:PRIETO-KOP
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 SHADY OAK LANE
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830
Mailing Address - Country:US
Mailing Address - Phone:706-554-5171
Mailing Address - Fax:
Practice Address - Street 1:315 LIBERTY STREET
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830
Practice Address - Country:US
Practice Address - Phone:706-554-4435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY23367.0820367500000X
COAPN.0005022-CRNA367500000X
GARN185024367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P20755Medicare UPIN