Provider Demographics
NPI:1689108987
Name:GODFREY, TIMOTHY (PA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:GODFREY
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 1:76 WILLOWBROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-7002
Mailing Address - Country:US
Mailing Address - Phone:862-246-7938
Mailing Address - Fax:
Practice Address - Street 1:76 WILLOWBROOK BLVD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-7002
Practice Address - Country:US
Practice Address - Phone:862-246-7938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-13
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00560000363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical