Basic Information
Provider Information
NPI: 1780101592
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: COGSWELL
FirstName: TIFFANY
MiddleName: ELAINE
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 278
Address2:  
City: AMITY
State: OR
PostalCode: 971010278
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 627 NE EVANS ST
Address2:  
City: MCMINNVILLE
State: OR
PostalCode: 971283923
CountryCode: US
TelephoneNumber: 5034347523
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/23/2017
LastUpdateDate: 08/23/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X  Y    

No ID Information.


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