Provider Demographics
NPI:1154576288
Name:MARTIN, TIFFANY (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 SILAS CREEK PKWY DEPT OF
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3013
Mailing Address - Country:US
Mailing Address - Phone:336-718-3150
Mailing Address - Fax:
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-3150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102859363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant