Healthcare Provider Details

I. General information

NPI: 1205089489
Provider Name (Legal Business Name): TIMOTHY JOHN KATSMA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 12/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5740 CRESTWOOD DR
OGDEN UT
84405-4869
US

IV. Provider business mailing address

5740 CRESTWOOD DR
OGDEN UT
84405-4869
US

V. Phone/Fax

Practice location:
  • Phone: 801-479-7792
  • Fax:
Mailing address:
  • Phone: 801-479-7771
  • Fax: 801-479-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number7139935-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: