Healthcare Provider Details

I. General information

NPI: 1710960497
Provider Name (Legal Business Name): TIMOTHY L BEWLEY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 WELLNESS WAY
LAMAR CO
81052-3867
US

IV. Provider business mailing address

201 KENDALL DR
LAMAR CO
81052-3939
US

V. Phone/Fax

Practice location:
  • Phone: 719-336-6976
  • Fax: 719-336-1221
Mailing address:
  • Phone: 719-336-0261
  • Fax: 719-336-0265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 362
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: