Provider Demographics
NPI:1982911012
Name:KATULS, TIFFANY (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:KATULS
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 1:5393 STONEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8931
Mailing Address - Country:US
Mailing Address - Phone:909-648-3928
Mailing Address - Fax:
Practice Address - Street 1:5857 PINE AVE
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-6536
Practice Address - Country:US
Practice Address - Phone:909-287-7474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant