Provider Demographics
NPI:1306572318
Name:LUND, TIMOTHY MERRILL (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MERRILL
Last Name:LUND
Suffix:
Gender:M
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 1:261 N ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2617
Mailing Address - Country:US
Mailing Address - Phone:480-677-8282
Mailing Address - Fax:
Practice Address - Street 1:8141 W CAMELBACK RD # B-101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85033-1050
Practice Address - Country:US
Practice Address - Phone:480-677-8282
Practice Address - Fax:480-535-0962
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-01
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9729363AM0700X
AZ363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ9729OtherARIZONA STATE PHYSICIAN ASSISTANT LICENSE NUMBER
AZ9729OtherARIZONA STATE LICENSE - ARIZONA REGULATORY BOARD OF PHYSICIAN ASSISTANTS