Healthcare Provider Details

I. General information

NPI: 1124742234
Provider Name (Legal Business Name): TIMOTHY PORTER OGRADY CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 10/03/2022
Certification Date: 10/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 N CHURCH AVE
TUCSON AZ
85701-1113
US

IV. Provider business mailing address

6310 N WHALEBACK PL
TUCSON AZ
85750-0824
US

V. Phone/Fax

Practice location:
  • Phone: 706-746-7575
  • Fax:
Mailing address:
  • Phone: 706-746-7575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number248626
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: