Healthcare Provider Details

I. General information

NPI: 1407769086
Provider Name (Legal Business Name): TIMOTHY A THARP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2744 WALLACE LAKE RD
MILTON FL
32571-9172
US

IV. Provider business mailing address

2186 JACKSON KELLER RD STE 2223
SAN ANTONIO TX
78213-2723
US

V. Phone/Fax

Practice location:
  • Phone: 850-816-9193
  • Fax:
Mailing address:
  • Phone: 850-816-9193
  • Fax: 937-962-6210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberCI
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: