Provider Demographics
NPI:1386896595
Name:ARCHER, TIFFANY JO (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:JO
Last Name:ARCHER
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 1:5016 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-3702
Mailing Address - Country:US
Mailing Address - Phone:785-215-1664
Mailing Address - Fax:
Practice Address - Street 1:5501 MARVIN SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-9007
Practice Address - Country:US
Practice Address - Phone:228-871-4033
Practice Address - Fax:228-871-3344
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01691363AM0700X
CA19896363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical