Provider Demographics
NPI:1306854005
Name:BOWERMAN, TIFFANY D (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:D
Last Name:BOWERMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:D
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 THREE RIVERS DR NE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-4999
Mailing Address - Country:US
Mailing Address - Phone:706-292-0040
Mailing Address - Fax:706-378-0556
Practice Address - Street 1:100 THREE RIVERS DR NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-4999
Practice Address - Country:US
Practice Address - Phone:706-292-0040
Practice Address - Fax:706-378-0556
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004084363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA480481221CMedicaid
GA480481221DMedicaid
GA480481221AMedicaid
GA480481221CMedicaid
GA480481221AMedicaid
GA4667320001Medicare NSC