Provider Demographics
NPI:1598802480
Name:BURGIN, TIFFANI DIANE (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANI
Middle Name:DIANE
Last Name:BURGIN
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 1:7703 FLOYD CURL DR # MC7977
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-450-9180
Mailing Address - Fax:210-450-2117
Practice Address - Street 1:4647 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-358-9144
Practice Address - Fax:210-358-8536
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04883363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX197423002Medicaid
TX197423003OtherCSHCN