Provider Demographics
NPI:1316969306
Name:SMITH, TIFFANY (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:OWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 731218
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-1218
Mailing Address - Country:US
Mailing Address - Phone:903-315-2032
Mailing Address - Fax:903-315-2719
Practice Address - Street 1:701 E MARSHALL AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5659
Practice Address - Country:US
Practice Address - Phone:903-315-2032
Practice Address - Fax:903-315-2719
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04787363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04787OtherTX MEDICAL BOARD LICENSE
TX86440NMedicare ID - Type Unspecified