Healthcare Provider Details

I. General information

NPI: 1285614313
Provider Name (Legal Business Name): TIMOTHY J DALE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EAST CARROLL STREET
SALISBURY MD
21801
US

IV. Provider business mailing address

PO BOX 3012
WILMINGTON DE
19804-0012
US

V. Phone/Fax

Practice location:
  • Phone: 410-543-7100
  • Fax: 410-546-6350
Mailing address:
  • Phone: 800-456-4629
  • Fax: 302-224-5678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0000607
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: