Provider Demographics
NPI:1760652283
Name:ROUSE, TIFFANY M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:M
Last Name:ROUSE
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:PO BOX 2239
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30514-2239
Mailing Address - Country:US
Mailing Address - Phone:706-745-2229
Mailing Address - Fax:706-745-0836
Practice Address - Street 1:63 PLEASANT HILL RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-2291
Practice Address - Country:US
Practice Address - Phone:706-745-2229
Practice Address - Fax:706-745-0836
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003539363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA907254555BMedicaid
GA97BBGLZMedicare PIN
GA907254555BMedicaid