Provider Demographics
NPI:1972636843
Name:JANICKI, TIA L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:L
Last Name:JANICKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:TIA
Other - Middle Name:L
Other - Last Name:CHIRICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:70 MIDTOWN PARK E
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-4140
Mailing Address - Country:US
Mailing Address - Phone:251-289-1786
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:70 MIDTOWN PARK E
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-4140
Practice Address - Country:US
Practice Address - Phone:251-289-1786
Practice Address - Fax:251-544-6406
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1780363A00000X
PAMA051858363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ37287Medicare UPIN
200924E59Medicare PIN
PA088481E59Medicare Oscar/Certification
Q37287Medicare UPIN