Provider Demographics
NPI:1467605725
Name:EBERSOHL, TIFFANY AMBER (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:AMBER
Last Name:EBERSOHL
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 1:6258 TOPIARY ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-3063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6258 TOPIARY ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-3063
Practice Address - Country:US
Practice Address - Phone:877-872-5788
Practice Address - Fax:866-462-7445
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19836363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1467605725Medicare UPIN