Provider Demographics
NPI:1710920178
Name:WILSON, TIFFANY KAY (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:KAY
Last Name:WILSON
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 1:412 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:HENRIETTA
Mailing Address - State:TX
Mailing Address - Zip Code:76365-3348
Mailing Address - Country:US
Mailing Address - Phone:940-235-3403
Mailing Address - Fax:580-272-0186
Practice Address - Street 1:412 W SOUTH ST
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:TX
Practice Address - Zip Code:76365-3348
Practice Address - Country:US
Practice Address - Phone:940-235-3403
Practice Address - Fax:580-272-0186
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2381363A00000X
TXPA04018363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185065301Medicaid
TX8F1345Medicare PIN
Q33576Medicare UPIN