Provider Demographics
NPI:1164527057
Name:SANDERSON, TIFFANY (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SANDERSON
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 1:3600 GASTON AVE
Mailing Address - Street 2:SUITE 907
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1800
Mailing Address - Country:US
Mailing Address - Phone:214-823-2052
Mailing Address - Fax:214-823-5747
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:SUITE 907
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-823-2052
Practice Address - Fax:214-823-5747
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04848363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA04848OtherPA LICENSE