MEDICARE: TIMOTHY PICKETT P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	4908815-1206	UT

General Provider Information

NPI Number	:	1427467158
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY PICKETT P.A.

Provider Business Mailing Address
First Line	:	5097 S 900 E STE 100
Second Line	:
City	:	SALT LAKE CTY
State	:	UT
Zip	:	84117-5725
Country	:	US
Telephone Number	:	801-851-5554
Fax Number	:

Provider Business Practice Location Address
First Line	:	5097 S 900 E STE 100
Second Line	:
City	:	SALT LAKE CTY
State	:	UT
Zip	:	84117-5725
Country	:	US
Telephone Number	:	801-851-5554
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/06/2014
Last Update Date	:	11/28/2023

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