Healthcare Provider Details

I. General information

NPI: 1275153967
Provider Name (Legal Business Name): TIMOTHY MCSHANE APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 KINGS HWY STE 100
WEST DEPTFORD NJ
08096-3165
US

IV. Provider business mailing address

765 ROUTE 70 E BLDG A100
MARLTON NJ
08053-2341
US

V. Phone/Fax

Practice location:
  • Phone: 856-251-0500
  • Fax: 856-797-4785
Mailing address:
  • Phone: 856-983-3900
  • Fax: 856-797-4785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01030100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: