Provider Demographics
NPI:1467526723
Name:BRYANT, TIFFANY ANN (PA)
Entity Type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:ANN
Last Name:BRYANT
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 1:1777 ASHLEY CIR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3339
Mailing Address - Country:US
Mailing Address - Phone:270-781-4090
Mailing Address - Fax:270-842-3133
Practice Address - Street 1:1777 ASHLEY CIR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3339
Practice Address - Country:US
Practice Address - Phone:270-781-4090
Practice Address - Fax:270-842-3133
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1385363A00000X
KYTC114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00698311OtherRR MEDICARE
TN1385OtherSTATE LICENSE
TN4193547OtherBCBS
TN1385OtherSTATE LICENSE
TN3665011Medicare ID - Type Unspecified
36650111Medicare PIN