Provider Demographics
NPI:1972960250
Name:HEESE, TIFFANY ELISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:ELISE
Last Name:HEESE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19284 STONE OAK PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3474
Mailing Address - Country:US
Mailing Address - Phone:210-268-1024
Mailing Address - Fax:210-268-0141
Practice Address - Street 1:19284 STONE OAK PKWY STE 102
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3474
Practice Address - Country:US
Practice Address - Phone:210-268-0124
Practice Address - Fax:210-268-0141
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60637513363A00000X, 363AM0700X
363A00000X
TXPA12294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2061724Medicaid
WAG001045700OtherGROUP PTAN(P)
WAG8954121Medicare PIN