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General NPI Number Information
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NPI Number | 1457911471
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Entity Type | Individual
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Provider Name | TIMOTHY ETHRIDGE PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/20/2019
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Last Update Date | 07/09/2024
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Provider Practice Location Address
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Address Line | 5955 ZEAMER AVE
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City | ANCHORAGE
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State | AK
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Zip | 99506-3702
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Country | US
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Telephone | 907-580-1711
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Fax | 111-111-1111
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Provider Business Mailing Address
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Address Line | 5955 ZEAMER AVE
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City | ANCHORAGE
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State | AK
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Zip | 99506-3702
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Country | US
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Telephone | 907-580-1711
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Fax | 111-111-1111
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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