Provider Demographics
NPI:1285872457
Name:GUNDLACH, TIMOTHY AARON (PA-C)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:AARON
Last Name:GUNDLACH
Suffix:
Gender:
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 1:4000 COAST GUARD BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-2135
Mailing Address - Country:US
Mailing Address - Phone:757-483-8536
Mailing Address - Fax:
Practice Address - Street 1:4000 COAST GUARD BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-2135
Practice Address - Country:US
Practice Address - Phone:757-301-9715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007705363A00000X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant