Provider Demographics
NPI:1144607201
Name:SMITH, TIMOTHY L (PA- C, ATC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA- C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 RIVERSIDE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-1304
Mailing Address - Country:US
Mailing Address - Phone:603-883-0091
Mailing Address - Fax:
Practice Address - Street 1:17 RIVERSIDE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062-1304
Practice Address - Country:US
Practice Address - Phone:603-883-0091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5368363A00000X
NH1138363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant