Provider Demographics
NPI:1306999156
Name:MACCURDY, TIMOTHY (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:MACCURDY
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 1:815 N CENTRAL AVE
Mailing Address - Street 2:STE C
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-5873
Mailing Address - Country:US
Mailing Address - Phone:541-734-9030
Mailing Address - Fax:541-734-9885
Practice Address - Street 1:3156 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-773-9772
Practice Address - Fax:541-773-1113
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA163288207N00000X, 363A00000X
WAPA10004497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8801740Medicare PIN