Provider Demographics
NPI:1770779126
Name:O'CONNOR, TIMOTHY MICHAEL (CNS)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11224-1410
Mailing Address - Country:US
Mailing Address - Phone:718-372-3300
Mailing Address - Fax:718-972-1314
Practice Address - Street 1:2928 W 36TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11224-1410
Practice Address - Country:US
Practice Address - Phone:718-372-3300
Practice Address - Fax:718-972-1314
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401805-1363LP0808X
MA278191163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04067387Medicaid