Provider Demographics
NPI:1518386945
Name:DESOUSA, TIMOTHY (CSFA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:DESOUSA
Suffix:
Gender:M
Credentials:CSFA
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 1460
Mailing Address - Street 2:
Mailing Address - City:HARDEEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29927-1460
Mailing Address - Country:US
Mailing Address - Phone:352-585-5581
Mailing Address - Fax:
Practice Address - Street 1:1316 HEARTHSTONE DR
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-7088
Practice Address - Country:US
Practice Address - Phone:352-585-5581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant