Healthcare Provider Details

I. General information

NPI: 1720860232
Provider Name (Legal Business Name): TIMOTHY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 N WERTH BLVD
NEWBERG OR
97132-7500
US

IV. Provider business mailing address

230 NE FIRCREST DR APT 301
MCMINNVILLE OR
97128-9214
US

V. Phone/Fax

Practice location:
  • Phone: 503-554-2521
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA223551
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: