Provider Demographics
NPI:1598310229
Name:TIFFANY, MADELINE LIZAIDA (PA)
Entity Type:Individual
Prefix:MRS
First Name:MADELINE
Middle Name:LIZAIDA
Last Name:TIFFANY
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 1:24665 STEWART ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2744
Mailing Address - Country:US
Mailing Address - Phone:956-998-2186
Mailing Address - Fax:
Practice Address - Street 1:24665 STEWART ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2744
Practice Address - Country:US
Practice Address - Phone:956-998-2186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant