Provider Demographics
NPI:1487094686
Name:IMHOFF, TIANA M (PA-C)
Entity type:Individual
Prefix:
First Name:TIANA
Middle Name:M
Last Name:IMHOFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIANA
Other - Middle Name:M
Other - Last Name:WEISS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1515 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:WI
Mailing Address - Zip Code:53925-1618
Mailing Address - Country:US
Mailing Address - Phone:920-623-2200
Mailing Address - Fax:
Practice Address - Street 1:1515 PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925
Practice Address - Country:US
Practice Address - Phone:920-623-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3158-23363AS0400X, 363AS0400X
WI1071822363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1487094686Medicaid
WIWEISSTIAOtherMERCYCARE INSURANCE
WI1487094686OtherBCBSWI
WI1487094686Medicaid