Healthcare Provider Details

I. General information

NPI: 1588585509
Provider Name (Legal Business Name): TIMOTHY SHIN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9841 BROKEN LAND PKWY STE 310
COLUMBIA MD
21046-1169
US

IV. Provider business mailing address

12222 MERIT DR STE 600
DALLAS TX
75251-3294
US

V. Phone/Fax

Practice location:
  • Phone: 443-276-7624
  • Fax:
Mailing address:
  • Phone: 972-715-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR279158
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: