Provider Demographics
NPI:1427467158
Name:PICKETT, TIMOTHY (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:PICKETT
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 1:5097 S 900 E STE 100
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CTY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5725
Mailing Address - Country:US
Mailing Address - Phone:801-851-5554
Mailing Address - Fax:
Practice Address - Street 1:5097 S 900 E STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CTY
Practice Address - State:UT
Practice Address - Zip Code:84117-5725
Practice Address - Country:US
Practice Address - Phone:801-851-5554
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4908815-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant