Basic Information
| Provider Information | |||||||||
| NPI: | 1750799359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAFFERTY | ||||||||
| FirstName: | TIMOTHY | ||||||||
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| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 149 HART ST | ||||||||
| Address2: | 82 MEDICAL GROUP/SGH | ||||||||
| City: | SHEPPARD AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 763113430 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 473 CABRILLO ST BLDG 422 | ||||||||
| Address2: | |||||||||
| City: | MONTEREY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939443201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539682252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2014 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 237167 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.