Provider Demographics
NPI:1851443436
Name:WIGHTMAN, TIFFANY RYSKAMP (PA C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RYSKAMP
Last Name:WIGHTMAN
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 1:1985 TATE BLVD SE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-1498
Mailing Address - Country:US
Mailing Address - Phone:828-328-5500
Mailing Address - Fax:828-485-2517
Practice Address - Street 1:1985 TATE BLVD SE
Practice Address - Street 2:SUITE 600
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-1498
Practice Address - Country:US
Practice Address - Phone:828-328-5500
Practice Address - Fax:828-485-2517
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1000889363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ30464Medicare UPIN
SCQ30464Medicare UPIN