Provider Demographics
NPI:1902194459
Name:EBEN, TIFFANY ANNE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:ANNE
Last Name:EBEN
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 1:11 RED HAWK RD N
Mailing Address - Street 2:
Mailing Address - City:COLTS NECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07722-2013
Mailing Address - Country:US
Mailing Address - Phone:818-917-1261
Mailing Address - Fax:
Practice Address - Street 1:1 ROBERT WOOD JOHNSON PL
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901
Practice Address - Country:US
Practice Address - Phone:818-917-1261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00258500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant