Provider Demographics
NPI:1538850532
Name:QUACH, TIFFANY CHANG
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CHANG
Last Name:QUACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7601 OCEAN HARBOR LN
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1537
Mailing Address - Country:US
Mailing Address - Phone:813-841-8056
Mailing Address - Fax:
Practice Address - Street 1:7601 OCEAN HARBOR LN
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1537
Practice Address - Country:US
Practice Address - Phone:813-841-8056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA9117697363A00000X
390200000X
MO2024022555363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program