Provider Demographics
NPI:1952304651
Name:HALSTEAD, TIMOTHY R (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:R
Last Name:HALSTEAD
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 1:703 TYLER ST. SUITE 252
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870
Mailing Address - Country:US
Mailing Address - Phone:419-609-8000
Mailing Address - Fax:419-609-8002
Practice Address - Street 1:703 TYLER ST. SUITE 252
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870
Practice Address - Country:US
Practice Address - Phone:419-609-8000
Practice Address - Fax:419-609-8002
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001298363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHHAPA13522Medicare PIN
OHS80616Medicare UPIN