Healthcare Provider Details

I. General information

NPI: 1114696069
Provider Name (Legal Business Name): TIMOTHY RYAN SHORT NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 11/03/2023
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 S CHARLES ST
ADRIAN MI
49221-2556
US

IV. Provider business mailing address

146 S CHARLES ST
ADRIAN MI
49221-2556
US

V. Phone/Fax

Practice location:
  • Phone: 517-366-5000
  • Fax: 517-366-5002
Mailing address:
  • Phone: 517-366-5000
  • Fax: 517-366-5002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704335486
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: