Provider Demographics
NPI:1689419384
Name:DAVIS, TIMOTHY (PTA)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 E BRIDGEPORT PARKWAY
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295
Mailing Address - Country:US
Mailing Address - Phone:847-373-2494
Mailing Address - Fax:
Practice Address - Street 1:115 E WILLIAMS FIELD RD STE 103
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-5231
Practice Address - Country:US
Practice Address - Phone:480-222-0655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ012559225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant