Provider Demographics
NPI:1801853569
Name:DUTTON, TIMOTHY R (PA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:DUTTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5708
Mailing Address - Country:US
Mailing Address - Phone:864-512-1417
Mailing Address - Fax:864-512-1823
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1787
Practice Address - Fax:864-222-8575
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA393510150AMedicaid
SCQM0668Medicaid
SCP00003708Medicare ID - Type UnspecifiedRAILROAD MEDICARE
SCP857271153Medicare PIN
SCQM0668Medicaid