Provider Demographics
NPI:1992249163
Name:BEYER, TIFFANY GALICIA
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:GALICIA
Last Name:BEYER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-4357
Mailing Address - Country:US
Mailing Address - Phone:203-688-1734
Mailing Address - Fax:
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-07
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54060363AM0700X
CT4711363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical