Provider Demographics
NPI:1093803157
Name:CHRISTIANSEN, TIFFANY (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:CHRISTIANSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 SHOUP AVE STE 17
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3653
Mailing Address - Country:US
Mailing Address - Phone:208-528-5892
Mailing Address - Fax:208-528-5747
Practice Address - Street 1:150 SHOUP AVE STE 17
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3653
Practice Address - Country:US
Practice Address - Phone:208-528-5892
Practice Address - Fax:208-528-5747
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA 623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant