Provider Demographics
NPI:1205167277
Name:KNOLL, TIMOTHY J (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:J
Last Name:KNOLL
Suffix:
Gender:M
Credentials:PA
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 13627
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85732-3627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6567 E CARONDELET DR
Practice Address - Street 2:SUITE 415
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-6152
Practice Address - Country:US
Practice Address - Phone:520-885-6701
Practice Address - Fax:520-885-9037
Is Sole Proprietor?:No
Enumeration Date:2010-01-14
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4581OtherSTATE LICENSE
AZ490827Medicaid
AZ490827Medicaid