Provider Demographics
NPI:1033993266
Name:KIM, TIFFANY (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:KIM
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 1:2592 N SANTIAGO BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-1862
Mailing Address - Country:US
Mailing Address - Phone:855-434-7763
Mailing Address - Fax:949-281-5550
Practice Address - Street 1:2592 N SANTIAGO BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-1862
Practice Address - Country:US
Practice Address - Phone:855-434-7763
Practice Address - Fax:949-281-5550
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-21
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA363A00000X
NVPA3007363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant