Healthcare Provider Details

I. General information

NPI: 1104868231
Provider Name (Legal Business Name): TIMOTHY ALAN PRESCOTT PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 12TH STREET EXT PRINCETON COMMUNITY HOSPITAL
PRINCETON WV
24740-2352
US

IV. Provider business mailing address

112 12TH ST
PRINCETON WV
24740-2312
US

V. Phone/Fax

Practice location:
  • Phone: 304-487-7275
  • Fax: 304-487-7153
Mailing address:
  • Phone: 865-985-7258
  • Fax: 865-985-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number934
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: