Provider Demographics
NPI:1700286077
Name:STANDON, TIMOTHY LAWRENCE (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LAWRENCE
Last Name:STANDON
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 1:16465 SIERRA LAKES PKWY
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-1242
Mailing Address - Country:US
Mailing Address - Phone:909-434-1150
Mailing Address - Fax:
Practice Address - Street 1:16465 SIERRA LAKES PKWY
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-1242
Practice Address - Country:US
Practice Address - Phone:909-434-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-24
Last Update Date:2014-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51862363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant