Basic Information
Provider Information
NPI: 1003295916
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CARTER
FirstName: TIMOTHY
MiddleName: JOE
NamePrefix: MR.
NameSuffix: II
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 4838 E. BASELINE ROAD
Address2: SUITE 108
City: MESA
State: AZ
PostalCode: 852064672
CountryCode: US
TelephoneNumber: 4809812400
FaxNumber: 4809812407
Practice Location
Address1: 1900 N. HIGLEY ROAD
Address2:  
City: GILBERT
State: AZ
PostalCode: 852341604
CountryCode: US
TelephoneNumber: 4809812400
FaxNumber: 4809812407
Other Information
ProviderEnumerationDate: 05/26/2015
LastUpdateDate: 04/08/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000X22032TNY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 
367500000XCRNA1137AZN Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

ID Information
IDTypeStateIssuerDescription
02914505AZ MEDICAID


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