Provider Demographics
NPI:1205012424
Name:HALL, TIFFANY S (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:S
Last Name:HALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:S
Other - Last Name:KALAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1500 109TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4670
Mailing Address - Country:US
Mailing Address - Phone:763-421-5011
Mailing Address - Fax:
Practice Address - Street 1:1500 109TH AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449
Practice Address - Country:US
Practice Address - Phone:763-421-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10653363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant