Provider Demographics
NPI:1851657241
Name:WIMSATT, TIFFANY JEANNE-MILLS (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:JEANNE-MILLS
Last Name:WIMSATT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:9871 BLUE LARKSPUR LN
Mailing Address - Street 2:STE 100
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-6535
Mailing Address - Country:US
Mailing Address - Phone:831-333-9008
Mailing Address - Fax:
Practice Address - Street 1:2780 BOB WALLACE AVE SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35805-4104
Practice Address - Country:US
Practice Address - Phone:256-533-4626
Practice Address - Fax:256-533-4710
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2019-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-03282363AM0700X
CA56953363AM0700X
ALPA-1193363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC9403AOtherMEDICARE PTAN