Provider Demographics
NPI:1588897623
Name:VORST, TIMOTHY LAVERN (MS-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:LAVERN
Last Name:VORST
Suffix:
Gender:M
Credentials:MS-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8606
Mailing Address - Country:US
Mailing Address - Phone:904-463-1292
Mailing Address - Fax:
Practice Address - Street 1:2165 HERSCHEL ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3819
Practice Address - Country:US
Practice Address - Phone:904-387-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2014-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAA204367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant