Provider Demographics
NPI:1750314225
Name:DOUGHTY, TIMOTHY C (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:C
Last Name:DOUGHTY
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 1:2420 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:KINGSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:93613-2733
Mailing Address - Country:US
Mailing Address - Phone:816-585-1850
Mailing Address - Fax:
Practice Address - Street 1:1141 ROSE AVENUE
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-2640
Practice Address - Country:US
Practice Address - Phone:559-891-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO145155163W00000X, 367500000X
CANA3913367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200305650AMedicaid
MO919046300Medicaid
CADH6112Medicare PIN
MO919046300Medicaid