Provider Demographics
NPI:1558320515
Name:HOCKENBERRY, TIMOTHY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:HOCKENBERRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 ABERFELDY RD
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89519-0986
Mailing Address - Country:US
Mailing Address - Phone:775-426-9115
Mailing Address - Fax:775-453-2188
Practice Address - Street 1:4930 ABERFELDY RD
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89519-0986
Practice Address - Country:US
Practice Address - Phone:775-426-9115
Practice Address - Fax:775-453-2188
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6060207Q00000X
MT12441207Q00000X
MN32396207Q00000X
WA60396764207Q00000X
CA130997207Q00000X
OR164791207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1558320515Medicaid
NV002001002Medicaid
CA1558320515Medicaid
WA2045019Medicaid
OR500665654Medicaid
MTM011000441Medicare PIN
MNH300247522Medicare PIN
ORR176576Medicare PIN
WA2045019Medicaid
WAG8939904Medicare PIN
NVAU324Medicare PIN