Provider Demographics
NPI:1518148873
Name:PACE, TIMOTHY WAYNE (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:PACE
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 1:7901 4TH ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-4399
Mailing Address - Country:US
Mailing Address - Phone:850-572-0296
Mailing Address - Fax:
Practice Address - Street 1:7702 MEANY AVE STE 101
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93308-5199
Practice Address - Country:US
Practice Address - Phone:661-843-7830
Practice Address - Fax:661-843-7831
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-15
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1939363A00000X
FLPA9104343363A00000X, 363AS0400X
ALPA644363AS0400X
MEPA1385363AS0400X
CAPA23139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102978408OtherMEDICARE PTAN
FL262936800Medicaid