Provider Demographics
NPI:1114924156
Name:FEARON, TIMOTHY OWEN (PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:OWEN
Last Name:FEARON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6245 N 24TH PKWY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-2029
Mailing Address - Country:US
Mailing Address - Phone:602-997-7844
Mailing Address - Fax:602-997-8020
Practice Address - Street 1:6245 N 24TH PKWY
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-2029
Practice Address - Country:US
Practice Address - Phone:602-997-7844
Practice Address - Fax:602-997-8020
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1202AMedicare ID - Type UnspecifiedMEDICARE PTPP PROVIDER #