Provider Demographics
NPI:1710210802
Name:EARLE, TIMOTHY TAYLOR (PA-C, PT)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:TAYLOR
Last Name:EARLE
Suffix:
Gender:M
Credentials:PA-C, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 MOORPARK AVE
Mailing Address - Street 2:SUITE 316
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2631
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2400 MOORPARK AVE
Practice Address - Street 2:SUITE 316
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2631
Practice Address - Country:US
Practice Address - Phone:408-885-5935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20197363A00000X
CA21007225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACJ310ZMedicare PIN