Provider Demographics
NPI:1104452218
Name:STARK, TIFFANY L (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:STARK
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1108 CREEKSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2574
Mailing Address - Country:US
Mailing Address - Phone:208-283-6535
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant