Provider Demographics
NPI:1790328623
Name:EVERETT, TIFFANY (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:EVERETT
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 1:2 WEST MARSHALL ST
Mailing Address - Street 2:APT 228
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220
Mailing Address - Country:US
Mailing Address - Phone:225-229-9454
Mailing Address - Fax:
Practice Address - Street 1:417 N 11TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5002
Practice Address - Country:US
Practice Address - Phone:225-229-9454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006876363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical