Healthcare Provider Details

I. General information

NPI: 1003295916
Provider Name (Legal Business Name): TIMOTHY JOE CARTER II CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2015
Last Update Date: 04/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 N. HIGLEY ROAD
GILBERT AZ
85234-1604
US

IV. Provider business mailing address

4838 E. BASELINE ROAD SUITE 108
MESA AZ
85206-4672
US

V. Phone/Fax

Practice location:
  • Phone: 480-981-2400
  • Fax: 480-981-2407
Mailing address:
  • Phone: 480-981-2400
  • Fax: 480-981-2407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA1137
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number22032
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: