Individual ProviderTimothy BlackPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersPractice Address200 NE Mother Joseph Pl, Suite 110, Vancouver, WA 98664(360) 254-6161PECOS EnrollmentBased on the most recent information from CMS, provider Timothy Black is legally eligible to order and refer claims for Part B, HHA, DME and PMD services.Part BMedicare Part BEnrolledHHAHome Health AgencyEnrolledDMEDurable Medical EquipmentEnrolledPMDPower Mobility DeviceEnrolledCMS last updated its PECOS records yesterday at 12:57 PM.Profile DetailsProvider ID1730167271Provider TypeIndividualFull NameBlack, TimothyTitleMr.CredentialPAGenderMaleSole ProprietorNoEnumeration Date1/5/2006Last Updated8/7/2018Contact InformationPractice LocationPractice Address200 NE Mother Joseph Pl, Suite 110, Vancouver, WA 98664Phone(360) 254-6161Fax(360) 449-1146Mailing LocationMailing Address200 NE Mother Joseph Pl Ste 210, Vancouver, WA 98664-3295Phone(360) 254-6161Fax(360) 449-1146Provider TaxonomiesCodeDescriptionLicenseCode363AS0400XPrimaryDescriptionPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersLicenseUnlisted IssuerWashingtonCode363A00000XDescriptionPhysician AssistantPhysician Assistants & Advanced Practice Nursing ProvidersLicensePA60650228Washington