Provider Demographics
NPI:1083952147
Name:PENHALLURICK, TIFFANY (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:PENHALLURICK
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 1:1600 E FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-8643
Mailing Address - Country:US
Mailing Address - Phone:951-765-1766
Mailing Address - Fax:
Practice Address - Street 1:1600 E FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-8643
Practice Address - Country:US
Practice Address - Phone:951-765-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant