Provider Demographics
NPI:1245784453
Name:LUCKEY, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LUCKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CANNERY ST
Mailing Address - Street 2:MARSHFIELD CLINIC GREENWOOD CENTER
Mailing Address - City:GREENWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:54437-9705
Mailing Address - Country:US
Mailing Address - Phone:715-267-6600
Mailing Address - Fax:715-267-6917
Practice Address - Street 1:102 CANNERY ST
Practice Address - Street 2:MARSHFIELD CLINIC GREENWOOD CENTER
Practice Address - City:GREENWOOD
Practice Address - State:WI
Practice Address - Zip Code:54437-9705
Practice Address - Country:US
Practice Address - Phone:715-267-6600
Practice Address - Fax:715-267-6917
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI3988363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant