Provider Demographics
NPI:1083954317
Name:MEYENBURG, TIMOTHY JOSEPH (CRNP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:MEYENBURG
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9368 READER LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-3922
Mailing Address - Country:US
Mailing Address - Phone:410-997-0758
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:CARDIAC SURGERY ICU
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-5382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-23
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR176700163WC0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine