Provider Demographics
NPI:1194167239
Name:POESCHEL, TIFFANY A (PA)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:A
Last Name:POESCHEL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:TERP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 28900
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54324-0900
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:920-405-5388
Practice Address - Street 1:1110 KEPLER DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-8306
Practice Address - Country:US
Practice Address - Phone:920-288-5555
Practice Address - Fax:920-288-5550
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1194167239Medicaid
WIK40037632/46236Medicare PIN
WIK400376230/01994Medicare PIN