Healthcare Provider Details

I. General information

NPI: 1114518818
Provider Name (Legal Business Name): TIMOTHY RYAN TIBERIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3039 GLENN VALLEY LN APT 306
INDIAN TRAIL NC
28079-0060
US

IV. Provider business mailing address

3039 GLENN VALLEY LN APT 306
INDIAN TRAIL NC
28079-0060
US

V. Phone/Fax

Practice location:
  • Phone: 313-910-3726
  • Fax:
Mailing address:
  • Phone: 313-910-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0008402
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: