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Individual
TIMOTHY B DIFFERENT
Active
Individual
TIMOTHY B DIFFERENT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
AP140173
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
394643601
—
TX
01
—
769641
MEDICARE
TX
01
—
8KP517
BCBS
TX
01
—
P02210751
MEDICARE RAIL ROAD
TX
Enumeration date
01/31/2019
Last updated
05/21/2019
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