Provider Demographics
NPI:1619056553
Name:DIESEL, TIMOTHY SEAN (DOM, PA-C)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:SEAN
Last Name:DIESEL
Suffix:
Gender:M
Credentials:DOM, PA-C
Other - Prefix:DR
Other - First Name:T
Other - Middle Name:SEAN
Other - Last Name:DIESEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DOM, PA-C
Mailing Address - Street 1:8100 CONSTITUTION PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7643
Mailing Address - Country:US
Mailing Address - Phone:505-291-2040
Mailing Address - Fax:
Practice Address - Street 1:1240 PENNSYLVANIA ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7441
Practice Address - Country:US
Practice Address - Phone:505-291-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM765171100000X
NMPA2009-0010363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No171100000XOther Service ProvidersAcupuncturist