Provider Demographics
NPI:1770970899
Name:MANSOURI, TIMOTHY WAYNE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:MANSOURI
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:MANSOURI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:8732 FLUTE CIR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-1742
Mailing Address - Country:US
Mailing Address - Phone:209-765-8297
Mailing Address - Fax:
Practice Address - Street 1:1600 CREEKSIDE DR STE 2400
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-3485
Practice Address - Country:US
Practice Address - Phone:916-932-4163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-16
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA656576163WP0000X
CA95003073163WP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0000XNursing Service ProvidersRegistered NursePain ManagementGroup - Single Specialty