Provider Demographics
NPI:1831132406
Name:CLARK, TIFFANY A (PAC)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:C
Other - Last Name:HIRSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:404 W FOUNTAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-2437
Mailing Address - Country:US
Mailing Address - Phone:507-377-6285
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2437
Practice Address - Country:US
Practice Address - Phone:507-373-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16777363A00000X
MN12149363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16777Medicaid
CAP89933Medicare UPIN
CAAV324ZMedicare PIN