Provider Demographics
NPI:1730643032
Name:DIFFERENT, TIMOTHY B (CRNA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:B
Last Name:DIFFERENT
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 847522
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7522
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:2026 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5822
Practice Address - Country:US
Practice Address - Phone:903-586-5678
Practice Address - Fax:903-541-4679
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140173367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX769641OtherMEDICARE
TX8KP517OtherBCBS
TX394643601Medicaid
TXP02210751OtherMEDICARE RAIL ROAD