Provider Demographics
NPI:1316938616
Name:WOOTTEN, TIMOTHY STEVEN (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:STEVEN
Last Name:WOOTTEN
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 1:1861 TRAIL WAY
Mailing Address - Street 2:
Mailing Address - City:TURLOCK
Mailing Address - State:CA
Mailing Address - Zip Code:95382-8654
Mailing Address - Country:US
Mailing Address - Phone:209-485-1306
Mailing Address - Fax:
Practice Address - Street 1:1861 TRAIL WAY
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-8654
Practice Address - Country:US
Practice Address - Phone:209-485-1306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA165810OtherBLUE SHIELD
CA0PA165810Medicaid
CA0PA165810Medicaid
CA0PA165812Medicare PIN
CABV430ZMedicare PIN