Provider Demographics
NPI:1790231223
Name:FLACK, TIMOTHY MARSHALL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MARSHALL
Last Name:FLACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-9021
Mailing Address - Country:US
Mailing Address - Phone:984-215-6595
Mailing Address - Fax:
Practice Address - Street 1:1617 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-9021
Practice Address - Country:US
Practice Address - Phone:984-215-6595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06646363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical