Healthcare Provider Details

I. General information

NPI: 1982711628
Provider Name (Legal Business Name): TIMOTHY W TOLLESTRUP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3035 W HORIZON RIDGE PKWY STE 120
HENDERSON NV
89052-4189
US

IV. Provider business mailing address

3035 W HORIZON RIDGE PKWY STE 120
HENDERSON NV
89052-4189
US

V. Phone/Fax

Practice location:
  • Phone: 702-666-0463
  • Fax: 702-666-0455
Mailing address:
  • Phone: 702-666-0463
  • Fax: 702-666-0455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License Number13209
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number13209
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: