Provider Demographics
NPI:1164822649
Name:COMERIE, TIFFANY RENEE (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENEE
Last Name:COMERIE
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 1:6122 GRAND CYPRESS CIR E
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-2343
Mailing Address - Country:US
Mailing Address - Phone:954-263-7262
Mailing Address - Fax:
Practice Address - Street 1:5000 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-1503
Practice Address - Country:US
Practice Address - Phone:954-263-7262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108164363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program