Provider Demographics
NPI:1992360978
Name:ALLEN, TIMOTHY
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
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 124
Mailing Address - Street 2:
Mailing Address - City:ROSE
Mailing Address - State:NY
Mailing Address - Zip Code:14542-0124
Mailing Address - Country:US
Mailing Address - Phone:315-576-0082
Mailing Address - Fax:
Practice Address - Street 1:1991 BALSLEY RD
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-6725
Practice Address - Country:US
Practice Address - Phone:315-539-9229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-06
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024254363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty