Provider Demographics
NPI:1578537106
Name:WELCH, TIFFANY (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WELCH
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 1:2161 W SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-3203
Mailing Address - Country:US
Mailing Address - Phone:770-267-4470
Mailing Address - Fax:
Practice Address - Street 1:2161 W SPRING ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-3203
Practice Address - Country:US
Practice Address - Phone:770-267-4470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL547541OtherHEALTHEASE
FL291681900Medicaid
DCSG075554OtherVISTA (MCD)