Provider Demographics
NPI:1013686930
Name:WILSON, TIFFANY S (DC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7046 HOLLYWOOD BLVD APT 204
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6058
Mailing Address - Country:US
Mailing Address - Phone:818-739-9892
Mailing Address - Fax:
Practice Address - Street 1:24 S WEBER ST STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-1928
Practice Address - Country:US
Practice Address - Phone:866-226-8576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnosticGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26-2707834Medicaid