Provider Demographics
NPI:1174669832
Name:PAINE, TIMOTHY GORDON (PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:GORDON
Last Name:PAINE
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 1:1940 116TH AVE NE
Mailing Address - Street 2:100
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3011
Mailing Address - Country:US
Mailing Address - Phone:425-451-0649
Mailing Address - Fax:425-451-0655
Practice Address - Street 1:1940 116TH AVE NE
Practice Address - Street 2:100
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3011
Practice Address - Country:US
Practice Address - Phone:425-451-0649
Practice Address - Fax:425-451-0655
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA0003843225100000X
CT003321225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8351652Medicaid
WA564578Medicare UPIN
WA8351652Medicaid