Provider Demographics
NPI:1265793756
Name:DOTY, TIMOTHY JAMES (PA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:JAMES
Last Name:DOTY
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 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4000
Mailing Address - Fax:
Practice Address - Street 1:1919 LINCOLN WAY
Practice Address - Street 2:415
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2527
Practice Address - Country:US
Practice Address - Phone:208-625-4595
Practice Address - Fax:208-625-4596
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-31
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant