Provider Demographics
NPI:1437134376
Name:THACKER, TIMOTHY (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:THACKER
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 1:945 BETHESDA DRIVE
Mailing Address - Street 2:200B
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1406
Mailing Address - Country:US
Mailing Address - Phone:740-455-4937
Mailing Address - Fax:740-455-4931
Practice Address - Street 1:2951 MAPLE AVENUE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1406
Practice Address - Country:US
Practice Address - Phone:740-387-6193
Practice Address - Fax:740-387-6738
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH139495367500000X
OHCOA.00754-NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0852091Medicaid
OHTH8243621Medicare PIN
OH0852091Medicaid