Healthcare Provider Details

I. General information

NPI: 1487624797
Provider Name (Legal Business Name): TIMOTHY A MCCREARY P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6822 EAST 1000 SOUTH
FORT DUCHESNE UT
84026
US

IV. Provider business mailing address

6822 EAST 1000 SOUTH
FORT DUCHESNE UT
84026
US

V. Phone/Fax

Practice location:
  • Phone: 435-725-6874
  • Fax:
Mailing address:
  • Phone: 435-725-6874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-18491
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7263849-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: