Healthcare Provider Details

I. General information

NPI: 1023062692
Provider Name (Legal Business Name): TIMOTHY JOSEPH CRISTMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 WILLIAMS WAY
MOAB UT
84532-2186
US

IV. Provider business mailing address

450 WILLIAMS WAY
MOAB UT
84532-2185
US

V. Phone/Fax

Practice location:
  • Phone: 435-719-3500
  • Fax:
Mailing address:
  • Phone: 435-719-3500
  • Fax: 435-719-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004057
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: