Provider Demographics
NPI:1053180265
Name:SHANK, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SHANK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 WELLNESS WAY
Mailing Address - Street 2:
Mailing Address - City:VALLEY SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95252-9736
Mailing Address - Country:US
Mailing Address - Phone:209-772-7070
Mailing Address - Fax:
Practice Address - Street 1:51 WELLNESS WAY
Practice Address - Street 2:
Practice Address - City:VALLEY SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95252-9736
Practice Address - Country:US
Practice Address - Phone:209-772-7070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027207363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily