Provider Demographics
NPI:1407935182
Name:BLOCKER, TIMOTHY DWAYNE (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DWAYNE
Last Name:BLOCKER
Suffix:
Gender:M
Credentials:CRNA
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 26580
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-6580
Mailing Address - Country:US
Mailing Address - Phone:336-832-7786
Mailing Address - Fax:
Practice Address - Street 1:1200 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1004
Practice Address - Country:US
Practice Address - Phone:336-832-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC070399367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8052476Medicaid
NC2606228Medicare ID - Type UnspecifiedMEDICARE