Provider Demographics
NPI:1699796078
Name:BOARD, TIMOTHY GERARD (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:GERARD
Last Name:BOARD
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 1:211 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-1003
Mailing Address - Country:US
Mailing Address - Phone:518-587-1141
Mailing Address - Fax:518-587-1152
Practice Address - Street 1:454 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5532
Practice Address - Country:US
Practice Address - Phone:518-587-1141
Practice Address - Fax:518-587-1152
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004631363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY709221OtherMVP
NY970016493OtherRAILROAD MEDICARE
NY000405957003OtherBLUE SHIELD
NY050510000097OtherFIDELIS CARE
NY050510000097OtherFIDELIS CARE
NY709221OtherMVP