Provider Demographics
NPI:1366250474
Name:PEMBERTON, TIMOTHY A (PA - S3)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:A
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:PA - S3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W 34TH ST APT 11C08
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-3067
Mailing Address - Country:US
Mailing Address - Phone:540-419-6256
Mailing Address - Fax:
Practice Address - Street 1:50 W 34TH ST APT 11C08
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-3067
Practice Address - Country:US
Practice Address - Phone:540-419-6256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program