Provider Demographics
NPI:1376541102
Name:DENNIS, TIMOTHY A (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:DENNIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1096
Mailing Address - Street 2:
Mailing Address - City:PANGUITCH
Mailing Address - State:UT
Mailing Address - Zip Code:84759
Mailing Address - Country:US
Mailing Address - Phone:435-676-8758
Mailing Address - Fax:435-676-2679
Practice Address - Street 1:224 N. 400 EAST
Practice Address - Street 2:
Practice Address - City:PANGUITCH
Practice Address - State:UT
Practice Address - Zip Code:84759
Practice Address - Country:US
Practice Address - Phone:435-676-8842
Practice Address - Fax:435-676-2679
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104445-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS22097Medicare UPIN