Provider Demographics
NPI:1891204772
Name:LY, TIFFANY TRACY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:TRACY
Last Name:LY
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 1:14044 W CAMELBACK RD STE 118
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-9481
Mailing Address - Country:US
Mailing Address - Phone:623-547-2600
Mailing Address - Fax:623-547-1899
Practice Address - Street 1:14044 W CAMELBACK RD STE 118
Practice Address - Street 2:
Practice Address - City:LITCHFIELD PARK
Practice Address - State:AZ
Practice Address - Zip Code:85340-9481
Practice Address - Country:US
Practice Address - Phone:623-547-2600
Practice Address - Fax:623-547-1899
Is Sole Proprietor?:No
Enumeration Date:2017-09-23
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant