Provider Demographics
NPI:1487624797
Name:MCCREARY, TIMOTHY A (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:MCCREARY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6822 EAST 1000 SOUTH
Mailing Address - Street 2:
Mailing Address - City:FORT DUCHESNE
Mailing Address - State:UT
Mailing Address - Zip Code:84026
Mailing Address - Country:US
Mailing Address - Phone:435-725-6874
Mailing Address - Fax:
Practice Address - Street 1:6822 EAST 1000 SOUTH
Practice Address - Street 2:
Practice Address - City:FORT DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-725-6874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA-18491363AM0700X
UT7263849-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806590100Medicaid
UT700000000009Medicaid
NMH1232Medicaid
UT700000000009Medicaid
ID806590100Medicaid
NM320057Medicare Oscar/Certification
UTHSZ216Medicare PIN