Provider Demographics
NPI:1265053680
Name:POPP, TIFFANI IRENE (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:IRENE
Last Name:POPP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIFFANI
Other - Middle Name:IRENE
Other - Last Name:CASTELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:501 WARD AVE
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-1661
Mailing Address - Country:US
Mailing Address - Phone:573-479-3036
Mailing Address - Fax:573-922-5083
Practice Address - Street 1:501 WARD AVE
Practice Address - Street 2:
Practice Address - City:CARUTHERSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63830-1661
Practice Address - Country:US
Practice Address - Phone:314-660-5918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2021034612363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program