Provider Demographics
NPI:1184113748
Name:MACON, TIMOTHY (PTA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MACON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 POTOMAC AVE SE APT 942
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-3749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6200 OREGON AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20015-1543
Practice Address - Country:US
Practice Address - Phone:202-541-0150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPTA000159225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant