Provider Demographics
NPI:1831149079
Name:KRIGBAUM, TIMOTHY (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:KRIGBAUM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 NE WYATT CT
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7687
Mailing Address - Country:US
Mailing Address - Phone:541-382-6447
Mailing Address - Fax:541-330-7413
Practice Address - Street 1:1245 NW 4TH ST STE 101
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1680
Practice Address - Country:US
Practice Address - Phone:541-548-7761
Practice Address - Fax:541-598-3485
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00998363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR105333Medicare ID - Type Unspecified
AZP52588Medicare UPIN