Healthcare Provider Details

I. General information

NPI: 1750314225
Provider Name (Legal Business Name): TIMOTHY C DOUGHTY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1141 ROSE AVENUE
SELMA CA
93662-2640
US

IV. Provider business mailing address

2420 HOWARD ST
KINGSBURG CA
93613-2733
US

V. Phone/Fax

Practice location:
  • Phone: 559-891-1000
  • Fax:
Mailing address:
  • Phone: 816-585-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number145155
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number145155
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA3913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: