Healthcare Provider Details

I. General information

NPI: 1346984861
Provider Name (Legal Business Name): TIMOTHY RYAN BARNES PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2022
Last Update Date: 04/21/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8220 MATISSE ST APT 1507
CHAMPIONS GATE FL
33896-8380
US

IV. Provider business mailing address

12170 CORTEZ BLVD
BROOKSVILLE FL
34613-5578
US

V. Phone/Fax

Practice location:
  • Phone: 181-348-2180
  • Fax:
Mailing address:
  • Phone: 352-279-4166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081H0002X
TaxonomyHospice and Palliative Medicine (Physical Medicine & Rehabilitation) Physician
License Number27043
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number27043
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: