Provider Demographics
NPI:1881681161
Name:THURSTON, TIMOTHY K (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:K
Last Name:THURSTON
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:PO BOX 636961
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6961
Mailing Address - Country:US
Mailing Address - Phone:513-981-5130
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:225 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 303
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-7914
Practice Address - Country:US
Practice Address - Phone:270-442-9463
Practice Address - Fax:270-442-2241
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA154363AM0700X
KYPA 154363AS0400X
IL085000805363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100183160Medicaid
KYP01012695OtherRAIL ROAD MEDICARE
KYP01012695OtherRAIL ROAD MEDICARE
KYK030180Medicare PIN