Provider Demographics
NPI:1699006718
Name:TIMOTHY, TOM PATRICK (PA)
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:PATRICK
Last Name:TIMOTHY
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 1:2149 BRANDON PARK CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-3946
Mailing Address - Country:US
Mailing Address - Phone:813-318-1382
Mailing Address - Fax:727-539-6118
Practice Address - Street 1:2817 ROCK MERRITT AVE
Practice Address - Street 2:
Practice Address - City:FT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28308
Practice Address - Country:US
Practice Address - Phone:907-910-0948
Practice Address - Fax:727-539-6118
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant