Provider Demographics
NPI:1134594823
Name:PETERSON, TIFFANY LYNN (PTA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9856 E LOUISIANA DR APT 3101
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80247-2402
Mailing Address - Country:US
Mailing Address - Phone:720-425-5434
Mailing Address - Fax:
Practice Address - Street 1:9856 E LOUISIANA DR APT 3101
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80247-2402
Practice Address - Country:US
Practice Address - Phone:720-425-5434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-07
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant