Provider Demographics
NPI:1952587206
Name:TIMS, PHILLIP BRADLEY
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BRADLEY
Last Name:TIMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N RAUL LONGORIA RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:SAN JUAN
Mailing Address - State:TX
Mailing Address - Zip Code:78589-3720
Mailing Address - Country:US
Mailing Address - Phone:956-782-5800
Mailing Address - Fax:956-782-5802
Practice Address - Street 1:1205 N RAUL LONGORIA RD
Practice Address - Street 2:SUITE I
Practice Address - City:SAN JUAN
Practice Address - State:TX
Practice Address - Zip Code:78589-3720
Practice Address - Country:US
Practice Address - Phone:956-782-5800
Practice Address - Fax:956-782-5802
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2060712225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2060712OtherSTATE LICENSE