Provider Demographics
NPI:1881842854
Name:LOCKE, TIFFANY GORAN (PA-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:GORAN
Last Name:LOCKE
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 1:4410 N MIDKIFF RD STE D6
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-4249
Mailing Address - Country:US
Mailing Address - Phone:432-689-6000
Mailing Address - Fax:432-689-6003
Practice Address - Street 1:4410 N MIDKIFF RD STE D6
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-4249
Practice Address - Country:US
Practice Address - Phone:432-689-6000
Practice Address - Fax:432-689-6003
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant