Provider Demographics
NPI:1841242278
Name:COOKE, TIFFANY L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:L
Last Name:COOKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:L
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13128 N 94TH DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4252
Mailing Address - Country:US
Mailing Address - Phone:623-876-8816
Mailing Address - Fax:623-298-0168
Practice Address - Street 1:13128 N 94TH DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4252
Practice Address - Country:US
Practice Address - Phone:623-876-8816
Practice Address - Fax:623-298-0168
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002318363A00000X
AZ3105363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ190206Medicare PIN