Provider Demographics
NPI:1790401479
Name:SPARROW, TIFFANY MOMOKO (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MOMOKO
Last Name:SPARROW
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 1:486 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-7622
Mailing Address - Country:US
Mailing Address - Phone:904-881-2077
Mailing Address - Fax:
Practice Address - Street 1:915 W MONROE ST STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-1177
Practice Address - Country:US
Practice Address - Phone:904-384-2240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116575363A00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant