Provider Demographics
NPI:1083678692
Name:MACK, TIFFANY L (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:MACK
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-0001
Practice Address - Country:US
Practice Address - Phone:608-263-7203
Practice Address - Fax:608-262-5624
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1922-023363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical