Provider Demographics
NPI:1932100203
Name:POTTS, TIFFANY ANN (PA)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:ANN
Last Name:POTTS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:ANN
Other - Last Name:CALLAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-4866
Practice Address - Fax:412-359-6620
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMA050954OtherMEDICAL PHYSICIAN ASST
PAMA050954OtherMEDICAL PHYSICIAN ASST
PA068796Medicare ID - Type Unspecified