Provider Demographics
NPI:1407297575
Name:CASPER, TIFFANY N (DO)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:N
Last Name:CASPER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:N
Other - Last Name:NESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54702-1510
Mailing Address - Country:US
Mailing Address - Phone:608-785-0940
Mailing Address - Fax:
Practice Address - Street 1:800 WEST AVE S
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601
Practice Address - Country:US
Practice Address - Phone:608-785-0940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4775-850390200000X
WI61382-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WICASPETIFOtherMERCYCARE INSURANCE
WI1407297575Medicaid
WI140297575OtherBCBSWI
WIK400147097-54176Medicare PIN