Provider Demographics
NPI:1104868231
Name:PRESCOTT, TIMOTHY ALAN (PAC)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:ALAN
Last Name:PRESCOTT
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2312
Mailing Address - Country:US
Mailing Address - Phone:865-985-7258
Mailing Address - Fax:865-985-7077
Practice Address - Street 1:122 12TH STREET EXT
Practice Address - Street 2:PRINCETON COMMUNITY HOSPITAL
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2352
Practice Address - Country:US
Practice Address - Phone:304-487-7275
Practice Address - Fax:304-487-7153
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2017-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00241089OtherMEDICARE RAILROAD
WV001902890OtherBLUE CROSS
WVPRPA19352Medicare PIN
WVP00241089OtherMEDICARE RAILROAD