Provider Demographics
NPI:1922610328
Name:KALLAM, TIMOTHY DEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DEVIN
Last Name:KALLAM
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 1:4985 FRIENDLY FARMS RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8213
Mailing Address - Country:US
Mailing Address - Phone:336-404-9023
Mailing Address - Fax:
Practice Address - Street 1:9915 PARK CEDAR DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8905
Practice Address - Country:US
Practice Address - Phone:704-544-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10336363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant