Provider Demographics
NPI:1790111607
Name:NGUYEN, TIFFANY CHARLENE (PA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CHARLENE
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:CHARLENE
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:619-554-7439
Mailing Address - Fax:
Practice Address - Street 1:971 LANE AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91914-3501
Practice Address - Country:US
Practice Address - Phone:858-554-7439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-24
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant