Provider Demographics
NPI:1992727416
Name:WORMUTH, TIFFANY KIDD (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:KIDD
Last Name:WORMUTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:K
Other - Last Name:WORMUTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1300 SENTARA PARK # 3
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-5884
Mailing Address - Country:US
Mailing Address - Phone:757-252-3050
Mailing Address - Fax:
Practice Address - Street 1:1300 SENTARA PARK # 3
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-5884
Practice Address - Country:US
Practice Address - Phone:757-252-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJDCATEMP-007343363A00000X
VA0110001946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10123038Medicaid
VAVV4755AMedicare PIN
VA10123038Medicaid
005455R25Medicare ID - Type UnspecifiedMEDICARE #
P00170588Medicare ID - Type UnspecifiedRAILROAD MEDICARE #