Provider Demographics
NPI:1932426640
Name:TAYLOR, TIFFANY (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3747 ROSWELL RD STE 213
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6227
Mailing Address - Country:US
Mailing Address - Phone:470-956-0250
Mailing Address - Fax:
Practice Address - Street 1:3747 ROSWELL RD STE 213
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-6227
Practice Address - Country:US
Practice Address - Phone:470-956-0250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA005828363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140192BMedicaid
AL168719Medicaid
AL168719Medicaid