Provider Demographics
NPI:1265721245
Name:MOGLIA, TIFFANY MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:MOGLIA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:MARIE
Other - Last Name:OLIVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:46 FELLSMERE ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01904-2018
Mailing Address - Country:US
Mailing Address - Phone:781-462-8556
Mailing Address - Fax:
Practice Address - Street 1:200 UNICORN PARK DR
Practice Address - Street 2:STE 201
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-3324
Practice Address - Country:US
Practice Address - Phone:781-782-1300
Practice Address - Fax:781-782-1350
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4108363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical