Basic Information
Provider Information
NPI: 1003298050
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ROSE
FirstName: TIFFANY
MiddleName: ANN
NamePrefix:  
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: MASON
OtherFirstName: TIFFANY
OtherMiddleName: ANN
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: PO BOX 844658
Address2:  
City: DALLAS
State: TX
PostalCode: 752844658
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 120 HILLCREST MEDICAL BLVD STE 200
Address2:  
City: WACO
State: TX
PostalCode: 767128950
CountryCode: US
TelephoneNumber: 2542970400
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/26/2015
LastUpdateDate: 09/20/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000XPA09855TXY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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