Provider Demographics
NPI:1790290047
Name:ROBERTSON, TIMOTHY MALCOM (PCA)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MALCOM
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 BLACKLOG ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT GAY
Mailing Address - State:WV
Mailing Address - Zip Code:25514
Mailing Address - Country:US
Mailing Address - Phone:304-356-4562
Mailing Address - Fax:304-558-4563
Practice Address - Street 1:184 BLACKLOG ROAD
Practice Address - Street 2:
Practice Address - City:FORT GAY
Practice Address - State:WV
Practice Address - Zip Code:25514
Practice Address - Country:US
Practice Address - Phone:304-272-6671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
3810027474OtherPROVIDER ID