Provider Demographics
NPI:1710265053
Name:REID, TIFFANY N (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:N
Last Name:REID
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:PO BOX 950202
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0202
Mailing Address - Country:US
Mailing Address - Phone:502-636-8004
Mailing Address - Fax:
Practice Address - Street 1:3 AUDUBON PLAZA DR
Practice Address - Street 2:STE. 560
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1300
Practice Address - Country:US
Practice Address - Phone:502-636-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10001296A363AM0700X, 363AS0400X
KYTC024363AS0400X
KYPA1644363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK021770OtherMEDICARE PTAN- NORTON CTS