Provider Demographics
NPI:1205698941
Name:EDMONSON, TIFFANY (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:EDMONSON
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 1:7050 BROOKHOLLOW WEST DR # 406666
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77240-0895
Mailing Address - Country:US
Mailing Address - Phone:606-706-2611
Mailing Address - Fax:
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9421
Practice Address - Country:US
Practice Address - Phone:606-706-2611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant