Provider Demographics
NPI:1154880797
Name:CHEATHAM, TIMOTHY JAMES
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:CHEATHAM
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 1:5020 WATERBURY WAY
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-4224
Mailing Address - Country:US
Mailing Address - Phone:916-837-2377
Mailing Address - Fax:
Practice Address - Street 1:2025 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2115
Practice Address - Country:US
Practice Address - Phone:916-973-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-13
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001090367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered