Provider Demographics
NPI:1306936166
Name:LASKE, TIFFANY G (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:G
Last Name:LASKE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:G
Other - Last Name:REVELS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:2334 SOUTH 41ST ST.
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:800-999-9883
Mailing Address - Fax:
Practice Address - Street 1:2334 SOUTH 41ST ST.
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:800-999-9883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-02177363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593063Medicare UPIN