Provider Demographics
NPI:1003298050
Name:ROSE, TIFFANY ANN (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:ROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:ANN
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 HILLCREST MEDICAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8950
Practice Address - Country:US
Practice Address - Phone:254-297-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-26
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant