Provider Demographics
NPI:1487834297
Name:SMITH, TIMOTHY D (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:7975 N HAYDEN RD
Mailing Address - Street 2:STE D354
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-3243
Mailing Address - Country:US
Mailing Address - Phone:480-214-9720
Mailing Address - Fax:480-214-9722
Practice Address - Street 1:15215 S 48TH ST
Practice Address - Street 2:SUITE 113
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-9142
Practice Address - Country:US
Practice Address - Phone:480-961-9299
Practice Address - Fax:480-961-1802
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2023-10-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ4778363A00000X, 363AS0400X
FLPA9104364363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264533500Medicaid
FLAH360ZMedicare PIN