Provider Demographics
NPI:1053896621
Name:SHANK, TIMOTHY RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:SHANK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 S VANCE ST APT A-305
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-5614
Mailing Address - Country:US
Mailing Address - Phone:610-331-8346
Mailing Address - Fax:
Practice Address - Street 1:12650 W 64TH AVE UNIT E501
Practice Address - Street 2:
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-3893
Practice Address - Country:US
Practice Address - Phone:303-431-4127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-30
Last Update Date:2018-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0005534363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0005534OtherCOLORADO PA LICENSE
1155401OtherNCCPA