Provider Demographics
NPI:1043533888
Name:HUBBARD, TIARA ROSE (PA)
Entity Type:Individual
Prefix:
First Name:TIARA
Middle Name:ROSE
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIARA
Other - Middle Name:ROSE
Other - Last Name:BURKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:11686 RED DOG RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-9509
Mailing Address - Country:US
Mailing Address - Phone:530-575-8423
Mailing Address - Fax:
Practice Address - Street 1:11815 EDUCATION ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95602-2410
Practice Address - Country:US
Practice Address - Phone:530-888-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-08
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant