Provider Demographics
NPI:1912279092
Name:STEWART, TIMOTHY ALLEN (ATC, PTA)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ALLEN
Last Name:STEWART
Suffix:
Gender:M
Credentials:ATC, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 POOR VALLEY CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-7319
Mailing Address - Country:US
Mailing Address - Phone:423-273-1011
Mailing Address - Fax:
Practice Address - Street 1:C&A PLAZA CALIFORNIA STREET
Practice Address - Street 2:SUITE 200
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68154
Practice Address - Country:US
Practice Address - Phone:402-891-1118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2079225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant