Provider Demographics
NPI:1710960497
Name:BEWLEY, TIMOTHY L (PAC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:BEWLEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:CO
Mailing Address - Zip Code:81052-3939
Mailing Address - Country:US
Mailing Address - Phone:719-336-0261
Mailing Address - Fax:719-336-0265
Practice Address - Street 1:2221 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:CO
Practice Address - Zip Code:81052-3867
Practice Address - Country:US
Practice Address - Phone:719-336-6976
Practice Address - Fax:719-336-1221
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA 362363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO78484260Medicaid
COMB3508148OtherDEA
COCO301137Medicare UPIN