Basic Information
| Provider Information | |||||||||
| NPI: | 1972593879 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SKINNER | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | MARC | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CTR | ||||||||
| Address2: | 9040 JACKSON AVE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539680780 | ||||||||
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| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CTR | ||||||||
| Address2: | 9040 JACKSON AVE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984311100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539680780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 03/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 004360 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8700171500 | 05 | KY | MEDICAID |