Provider Demographics
NPI:1578934402
Name:PRIMROSE, TIMOTHY (NP)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PRIMROSE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 CEDAR ST STE 405
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2057
Mailing Address - Country:US
Mailing Address - Phone:574-335-8707
Mailing Address - Fax:574-335-0741
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-335-4145
Practice Address - Fax:574-335-4146
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005880A363L00000X, 363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000969840OtherBCBS
IN201327760Medicaid
IN000000969840OtherBCBS