Healthcare Provider Details

I. General information

NPI: 1518226356
Provider Name (Legal Business Name): TIMOTHY P WOMBACHER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2012
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 DEMPSTER ST
PARK RIDGE IL
60068-1143
US

IV. Provider business mailing address

11970 N CENTRAL EXPY STE 210
DALLAS TX
75243-3784
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-7025
  • Fax: 708-783-7409
Mailing address:
  • Phone: 214-575-5885
  • Fax: 907-782-4662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12692
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085005389
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: