Provider Demographics
NPI:1679568968
Name:VIVIAN, TIMOTHY E (PA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:E
Last Name:VIVIAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 SOUTH JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0949
Mailing Address - Country:US
Mailing Address - Phone:931-520-0148
Mailing Address - Fax:931-520-0152
Practice Address - Street 1:675 SOUTH JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0949
Practice Address - Country:US
Practice Address - Phone:931-520-0148
Practice Address - Fax:931-520-0152
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0770363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP36605Medicare UPIN
TN3669495Medicare ID - Type Unspecified