Provider Demographics
NPI:1568501054
Name:SIMRELL, TIMOTHY MARTIN (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MARTIN
Last Name:SIMRELL
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 1:6332 N OBERLIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-4153
Mailing Address - Country:US
Mailing Address - Phone:503-757-8202
Mailing Address - Fax:
Practice Address - Street 1:10300 NE HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3831
Practice Address - Country:US
Practice Address - Phone:503-257-5500
Practice Address - Fax:503-257-5673
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR143167Medicare PIN