Provider Demographics
NPI:1619164654
Name:SWENSON, TIFFANY D (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:D
Last Name:SWENSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1702 UNIVERSITY DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-4940
Mailing Address - Country:US
Mailing Address - Phone:701-364-8000
Mailing Address - Fax:
Practice Address - Street 1:1401 13TH AVE E
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-3468
Practice Address - Country:US
Practice Address - Phone:701-364-5751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0403363AM0700X, 363A00000X
MN10357363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053111OtherPREFERRED ONE
MNPENDINGOtherMN BCBS
ND30111OtherBCBS
HP84398OtherHEALTH PARTNERS
MN325452000Medicaid
0128334OtherMEDICA
MNPENDINGOtherMN BCBS
ND715958Medicare PIN