Provider Demographics
NPI:1972741692
Name:COLVIN, TIFFANY NICOLE (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:COLVIN
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 1:7016 NORMANDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-6206
Mailing Address - Country:US
Mailing Address - Phone:904-783-9428
Mailing Address - Fax:904-786-4981
Practice Address - Street 1:7016 NORMANDY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-6206
Practice Address - Country:US
Practice Address - Phone:904-783-9428
Practice Address - Fax:904-786-4981
Is Sole Proprietor?:No
Enumeration Date:2009-02-03
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104910363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1085909OtherNCCPA
FL018268500Medicaid
FLPA9104910OtherMEDICAL LICENSE
FL018268500Medicaid