Provider Demographics
NPI:1205959756
Name:COUGHENOUR, TIFFANY C (PA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:C
Last Name:COUGHENOUR
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:2985 CORTEZ AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7554
Mailing Address - Country:US
Mailing Address - Phone:208-535-4300
Mailing Address - Fax:208-535-4315
Practice Address - Street 1:3200 CHANNING WAY
Practice Address - Street 2:STE 205
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7546
Practice Address - Country:US
Practice Address - Phone:208-535-4300
Practice Address - Fax:208-535-4315
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2016-09-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IDPA244363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805523500Medicaid
IDS91641Medicare UPIN
ID805523500Medicaid