Provider Demographics
NPI:1750327706
Name:MAIN, TIFFANY K (NP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:K
Last Name:MAIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-6400
Mailing Address - Fax:417-347-6404
Practice Address - Street 1:1902 S US HWY 59
Practice Address - Street 2:CLINIC BLDG STE 1
Practice Address - City:PARSON
Practice Address - State:KS
Practice Address - Zip Code:67357
Practice Address - Country:US
Practice Address - Phone:417-347-6400
Practice Address - Fax:417-347-6404
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2015-03-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KS45333363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100850610AMedicaid
KS100429300AMedicaid
KS160904OtherKS BCBS
MO425962602Medicaid
500027083OtherRR MEDICARE
OK100850610AMedicaid
KS100429300AMedicaid