Basic Information
| Provider Information | |||||||||
| NPI: | 1922258821 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHRISTOPHER | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | GENET | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A.-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURNSIDE | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | GENET | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8765 AERO DR | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585410181 | ||||||||
| FaxNumber: | 8584300919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2008 | ||||||||
| LastUpdateDate: | 01/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-C19942 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 19942 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | GR0066310 | 05 | CA | MEDICAID |