Provider Demographics
NPI:1477289494
Name:HENLEY, TIMOTHY EDWARD (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:EDWARD
Last Name:HENLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 ROBERTS RD
Mailing Address - Street 2:
Mailing Address - City:SANDIA PARK
Mailing Address - State:NM
Mailing Address - Zip Code:87047-9352
Mailing Address - Country:US
Mailing Address - Phone:505-977-0144
Mailing Address - Fax:
Practice Address - Street 1:35 ROBERTS RD
Practice Address - Street 2:
Practice Address - City:SANDIA PARK
Practice Address - State:NM
Practice Address - Zip Code:87047-9352
Practice Address - Country:US
Practice Address - Phone:505-977-0144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2023-0309363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant