Healthcare Provider Details

I. General information

NPI: 1558457754
Provider Name (Legal Business Name): TIMOTHY PAYNE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 WALLACE WAY
GRANDVIEW WA
98930-8805
US

IV. Provider business mailing address

PO BOX 190
TOPPENISH WA
98948-0190
US

V. Phone/Fax

Practice location:
  • Phone: 509-882-3444
  • Fax: 509-882-2049
Mailing address:
  • Phone: 509-865-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10000956
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: