Provider Demographics
NPI:1679536148
Name:STALLARD, TIMOTHY C (PA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:C
Last Name:STALLARD
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:23401 PRAIRIE STAR PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66227-7268
Mailing Address - Country:US
Mailing Address - Phone:913-677-6319
Mailing Address - Fax:913-677-1540
Practice Address - Street 1:23401 PRAIRIE STAR PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66227-7268
Practice Address - Country:US
Practice Address - Phone:913-677-6319
Practice Address - Fax:913-677-1540
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2013-10-30
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Provider Licenses
StateLicense IDTaxonomies
KS1500547363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100365450AMedicaid
KS042486Medicare ID - Type Unspecified
KSS48257Medicare UPIN