Basic Information
| Provider Information | |||||||||
| NPI: | 1174512347 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIMOTHY | ||||||||
| FirstName: | STEPHANIA | ||||||||
| MiddleName: | KAY CAMPBELL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 N TAYLOR ST | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812302296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706411456 | ||||||||
| FaxNumber: | 9706414461 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 N NEVADA AVE | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197768040 | ||||||||
| FaxNumber: | 7197766820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD00047323 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | DR.0040596 | CO | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0216073 | 01 | WA | L&I | OTHER | 8470361 | 05 | WA | MEDICAID |