Provider Demographics
NPI:1164654414
Name:TIMOTHY W TOLLESTRUP PC
Entity Type:Organization
Organization Name:TIMOTHY W TOLLESTRUP PC
Other - Org Name:NEUROPAX CLINIC OF NEVADA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:TOLLESTRUP
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-666-0463
Mailing Address - Street 1:3035 W HORIZON RIDGE PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4189
Mailing Address - Country:US
Mailing Address - Phone:702-666-0463
Mailing Address - Fax:702-666-0463
Practice Address - Street 1:3035 W HORIZON RIDGE PKWY STE 120
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4189
Practice Address - Country:US
Practice Address - Phone:702-666-0463
Practice Address - Fax:702-666-0463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVCS729AMedicare PIN